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AGENDA

PART 1 Please look over the agenda and think about which of these topics might present an area of conflict for you.

This means an item where a decision or recommendation made may advantage you, your family, and your workplace or business interests. These advantages might be financial or in another form, perhaps the ability to exert unseen influence.

Where anything on the agenda has the potential to put you in such a position, or is raised during the meeting, you should tell us all about it. This means we can ensure that our decisions, recommendations or actions can be protected from the impact of any possible conflict you or others could have.

If you are unsure, it is always best to raise the possibility with the Chair before the meeting, or at any point during the meeting.

This openness is important as we can all discuss how to manage decision making in a complex environment that involves public money.

Item

Lead Action required Papers

Page No

1. Introduction

1.1 Apologies for Absence Declarations of Interest Declarations of Gifts and Hospitality

Chair Note

In addition to being published with this agenda, the Register of Interests is available on the CCG’s website (www.islingtonccg.nhs.uk) or from the Business Support Team, 2nd Floor Laycock PDC, Laycock Street, London, N1 1TH

1.2 Chair’s Introduction and Opening Remarks

Chair Note

1.3 Minutes and Actions of the Meeting held on 14th March 2018

Chair

For approval

1.3 1.3.1

4 14

1.4 Matters Arising Chair --

1.5 Questions from the Public Chair --

Islington Clinical Commissioning Group Governing Body Business Meeting Wednesday, 9 May 2018 9.30-11.30 Laycock PDC, Laycock Street London N1 1TH

http://www.islingtonccg.nhs.uk/

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Item


Page No

NB: Members of the public will be given the opportunity to ask questions. These must relate to items that are on the agenda for this meeting and should not take longer than three minutes per person.

2. Overview Reports 2.1 Accountable Officer’s Report

Accountable

Officer For approval 2.1 19

3. Quality, Performance and Finance 3.1 Finance Report

Chief

Finance Officer

For discussion

3.1 25

3.2 Performance Report

Director of Planning,

Performance and Delivery

For discussion

3.2 3.2.1

38 48

3.3

Pre-Consultation Business Case for the Redevelopment of the St Pancras Hospital site and Mental Health Community Hubs

Chief Operating

Officer

For approval 3.3 3.3.1

3.4 Request to Delegate Authority for Approval of the Annual Report and Accounts to the Islington CCG Audit Committee

Chief Operating

Officer

For approval 3.4 122

4. Governance and Assurance

4.1 Governing Body Risk Assurance Framework (With NCL Section of Risk Reports)



For discussion

4.1 4.1.1 4.1.2 4.1.3 4.1.4 4.1.5

124 129 153 156 160 162

4.2 Audit Committee In Common – Terms of Reference (TOR)

NCL Chief Finance Officer

For approval 4.2 4.2.1 4.2.2 4.2.3

164 166 169 178

5. For Information 5.1 Minutes of the Quality &

Performance Committee – available here

Chair, Quality &

Performance Committee

To note 5.1

5.2 Minutes of the Patient and Public Participation Committee

Chair, Patient and Public

Participation Committee

To note 5.2

http://iccg-root.nhs.sitekit.net/CCG/Downloads/CCG/BoardPapers/2018/20180509/5.1%20-%20QP%20Minutes%2013%20February%202018%20-%20APPROVED.docx

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5.3 Minutes of the Strategy & Finance Committee - available here

Chair, Strategy & Finance

Committee

To note 5.3

5.4 NCL Primary Care Joint Committee minutes - available here

To note 5.4

5.5 NCL Joint Committee minutes – available here

To note 5.5

6. Any Other Business Date of Next Meeting – Wednesday 11th July 2018, 9.30 - 11.30

http://iccg-root.nhs.sitekit.net/CCG/Downloads/CCG/BoardPapers/2018/20180509/5.3%20-%20SF%20minutes%2029%20March%202018%20-%20APPROVED.docx

http://iccg-root.nhs.sitekit.net/CCG/Downloads/CCG/BoardPapers/2018/20180509/5.4%20-%20Approved%20PCC%20Part%20I%20mins%20and%20actions%20from%2022%20March%202018.docx

http://iccg-root.nhs.sitekit.net/CCG/Downloads/CCG/BoardPapers/2018/20180509/5.5%20-%20%20JCC%20minutes%20Feb%202018.doc

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Item: 1.3

Part One Minutes Meeting of the Islington Clinical Commissioning Group

Governing Body 14th March 2018

Laycock PDC, Laycock Street, London, N1 1TH Members Present: Dr Jo Sauvage Sorrel Brookes

Chair, Islington Clinical Commissioning Group Lay Vice Chair

Lucy de Groot Lay Member Dr Rue Roy North Locality GP Representative Dr Rathini Ratnavel Jennie Hurley Dr Karen Sennett Helen Pettersen Simon Goodwin Deborah Snook

South West Locality GP Representative Practice Nurse Representative South East Locality GP Representative NCL Accountable Officer NCL Chief Finance Officer Practice Manager Representative

Non-Voting Members: Clare Henderson Rachel Lissauer Alex Smith

Director of Commissioning Director of Wellbeing Partnership Director of Planning, Performance and Delivery

Anthony Browne Will Huxter Tony Hoolaghan

Deputy Chief Finance Officer Director of Strategy Chief Operating Officer

In attendance: Dr Imogen Bloor Julie Billett Rose McDonald Dr Katie Coleman Rosie Peregrine-Jones Jess Macgregor Apologies: Shelagh Prosser Jennie Williams Sara Lightowlers Paul Sinden Sarah Mcilwaine Not expected: Ian Huckle

Primary Care Lead Director of Public Health for Camden and Islington Healthwatch Observer GP Representative Assistant Director of Quality & Safety (Haringey CCG) Service Director Adult Social Care Strategy & Commissioning Healthwatch Observer Director of Quality & Executive Nurse Secondary Care Consultant representative NCL Director of Acute Commissioning and Performance Director of Care Closer to Home Practice Manager Representative (job share)

Minutes: Karl Thompson Head of NCL Corporate Services

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1 Introduction

1.1 Apologies for Absence and Declarations of Interest Jo Sauvage noted apologies from Sorrel Brookes, Shelagh Prosser, Jennie Williams, Sarah Lightowlers, Paul Sinden, Sarah Mcilwaine and that the practice manager role as being covered this month by Deborah Snook. Jo Sauvage reiterated the importance of managing conflicts and noted the statement included in the agenda, regarding the ongoing importance and the responsibilities everyone has in this respect. Jo Sauvage declared that she is a GP provider and that her practice was a member of the local GP Federation. Jo Sauvage clarified that all GP and practice members of the Governing Body are linked to GP practices who also form part of the membership of the Islington GP Federation. Jo Sauvage also reiterated the importance of completing the gifts and hospitality register as appropriate.

1.2 Chair’s Introduction and opening Remarks Jo Sauvage welcomed everyone to the meeting and reiterated the hard work continuing across teams in support of the ongoing winter pressures.

1.3

Minutes and Actions of the Meeting held on 10th January 2018

1.3.1 Minutes Part 1 Amendments as follows: Katie Coleman asked for her new positon with the Islington GP Federation, to be recorded as GP Director for the GP Federation. Katie Coleman asked that the iHub audit date be captured, noting when this would be available for review. Deborah Snook asked if reference to patient representatives should be amend to community members as she understood this was the correct title. Simon Goodwin also noted that Barnet Governing Body had now supported the recommendation for NCL CCG audit Committees to meet in common with some minor amendments to the terms of reference

The minutes for Part 1 of the meeting on 10th January 2018 were APPROVED as an accurate record subject to the above changes. Part 2 Amendments as follows:

• 2.0 – Replace the word ‘not’ in the last sentence with the word ‘into’ The minutes for Part 2 of the meeting on 10th January 2018 were APPROVED as an accurate record subject to the above change.

JS

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Action Log The following updates were provided:

• Jennie Hurley reiterated her request that when the CCG refer to the 'GP Five Year Forward View' that we also include the '10 Point Plan for general Practice Nursing'

• Karen Sennett amended the action relating to LAS. It was clarified that this was a request for information regarding the percentage of calls made to 111 that subsequently result in an ambulance conveyance that are assessed by a clinician. Alex Smith agreed to find out from Enfield CCG, if this information could be provided, as lead commissioner.

• Deborah Snook asked on behalf of Ian Huckle if the action related to RTT could be updated to request if some regular data could be added to the performance report.

• In respect to the iHub performance review and audit, Lucy de Groot asked that this be noted as an action. Clare Henderson confirmed the review preparation was underway and that the Strategy and Finance committee would receive a report in June 2018

ACTION: 14/03 – 01 Jennie Hurley reiterated her request that when the CCG refer to the 'GP Five Year Forward View' that we also include the '10 Point Plan for general Practice Nursing' ACTION: 14/03 – 02 In respect to the iHub performance review and audit, Lucy de Groot asked that this be noted as an action. Clare Henderson confirmed the review preparation was underway and that the Strategy and Finance committee would receive a report in June 2018 ACTION: 14/03 – 03 Alex Smith to find out from Enfield CCG, if they can provide information on the percentage of calls made to 111, as lead commissioner.

1.4 Matters Arising • None

1.5

Questions from the Public

• A representative from ‘Islington ADHD Champions’ provided the following statement

We would like to thank the CCG efforts especially Jill Britton for her help in addressing the shortfall in care. Sadly, instead of having a care driven health care system, a target driven culture has developed. Our efforts will now be directed on a national level. We do hope that Islington CCG will continue with the actions it has set out with in improving services for ADHD service users.

Jo Sauvage thanked Islington ADHD Champions for their comments and expressed her thanks for their input and wished them good luck with their future national role.

Tony Hoolaghan confirmed he would pass on the thanks to Jill Britton for her good work.

2 Overview Reports 2.1

Accountable Officers Report All referred to the Accountable Officers Report that was circulated ahead of the meeting. Helen Pettersen referred members to the following highlights in her report:

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• St Pancras Hospital redevelopment – Tony Hoolaghan continues to develop the public consultation documentation which is likely to be available for public consultation during late Spring or early Summer 2018.

• Moorfields eye hospital – early discussions with the hospital continue regarding a potential move to the re-developed St Pancras Hospital site with a further update due at the Governing Body meeting in May 2018

• Staff Survey results – Tony Hoolaghan is leading a cross section of staff from both Haringey and Islington CCGs to review the feedback. Overall there were very positive remarks, although there remains room for improvement which will be worked on by the staff representatives and the executive team

• Internal audit and counter fraud services – the procurement process has now completed and the contract for NCL CCGs has been awarded to RSM Risk Assurance Services who are the current provider. The contract is for three years with an option to extend for a further two. Chairs action was sought in February to approve the re-appointment and the Governing Body were asked to ratify this decision

• NEL Commissioning Support Unit – a notice letter was issued to take in-house contract management services and acute medicines management services. A project group met on 22nd February 2018 to commence review of the project plan and associated risks and additionally confirmed that the five NCL CCGs would be asked to approve the final business case. Given the timescales it was requested that this be delegated to the sub group to make the decision. Ian Huckle is keen for the Governing Body to make the decision and so the Chair indicated that a sensible compromise would be to review any business case outside of a formal Governing Body meeting, adopting the urgent decisions process and that this would then be ratified at a future Governing Body meeting

• Haringey and Islington CCG Committees – work is underway to streamline decision making and reduce duplication through committees initially meeting in common, with the potential for joint committees to be established, in the future, where appropriate

• A Remuneration Committee in common took place on 1st March 2018 and supported the recommendation for the creation of the following two new posts:

o Director of Acute Commissioning and Director of Performance, Planning and Primary Care

o These posts have been created by splitting the existing NCL Director of Acute Commissioning and Performance role

o Paul Sinden was confirmed as moving into the Director of Performance, Planning and Primary Care role

o The Governing Body were asked to NOTE the decision taken as delegated authority had been given to the remuneration committee

Helen Pettersen concluded her update and asked if there were any questions in relation to the report.

• Katie Coleman supported the change to the NCL Director roles and asked for assurance that primary care would receive sufficient attention given the complexity of the area. Helen Pettersen explained that with the additional resource and with the proposed changes to move contracts management into the CCGs, that there should be an increased focus

• Simon Goodwin explained that the funding for the additional post would be met from reducing the existing costs attributed to the Healthy London Partnership programme

• Lucy de Groot asked for a summary of the source of funding in relation to the new NCL post for Director of Acute Commissioning

• Deborah Snook asked in relation to the Staff Survey results, what arrangements were in place regarding supporting staff to speak up. Tony Hoolaghan explained that under guidance for ‘Freedom To Speak Up’ that there are mechanisms in place and that the reference regarding concerns over bullying and harassment was made by a very small number of respondents

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although it was recognised that this issue would be taken seriously in order to ensure that all staff felt supported in the work place

In addition, Helen Pettersen noted that Whittington Health and Camden & Islington Foundation Trust (CIFT) had both done very well in achieving a rating of ‘good’ at their recent Care Quality Commission (CQC) inspections. Rathini Ratnaval noted that within the CIFT report, there were two services that received outstanding ratings – The Community Aging Service and Substance Misuse Service. The Substance Misuse Service is currently only a Camden service although from the 1st April 2018, this is being extended to Islington residents. ACTION: 14/03 - 04 Lucy de Groot asked for a summary of the source of funding in relation to the new NCL post for Director of Acute Commissioning

2.1.2 The Governing Body;

1) NOTED the report and 2) NOTED that an urgent decision regarding the NELCSU contract would be

taken outside of the formal Governing Body meeting 3) RATIFIED the decision taken by the Remuneration Committee taken under

Chairs Action

3 Quality, Performance and Finance 3.1 Finance Report

All referred to the Finance Report that was circulated ahead of the meeting.

Anthony Browne highlighted a number of key points in the report:

• An improved in-year surplus of £2.5M was reported, noting this was mainly the result of non-recurrent items off setting underlying pressure

• Acute contracting forecast an overall pressure of £3.6M at year end • UCLH continue to pose the greatest risk to CCG financial performance with a

£2.4M year end forecast variance • Non acute services are forecasting a year end £1.6M overspend. The overall

non acute position moved adversely from month 9 due to increases within the continuing healthcare and prescribing costs

• Reference was made to table 3.11 in which underspends in diagnostics and maternity were noted. Diagnostic underspend relates to a drop in MRI scans

• Non elective outpatient pressure was also noted with the mitigation that this would be the focus of the developing care closer to home integrated networks (CHINs) and quality improvement support team (QIST) activity during 2018-19

• Whittington Health have experienced a spike in general A&E attendance although a reduction in mental health concerns

• Royal Free are recognised to have a 2017-18 plan artificially high and as such significant variance remain which will be rectified for 2018-19 contracting round

• QIPP full year performance is reporting a slippage of £3.9M against the target of £11.7M. This relates mainly to delays in planned care

• QIPP risks were noted and it was reported that pressure can be offset by non-recurrent mitigating items allowing the year end forecast surplus of £2.5M to still be achieved

Simon Goodwin provided the following update:

• For 2017-18 it was reiterated that the surplus being declared for Islington is supported by £7.5M of non-recurrent contingency funding

• For month 10 there has been greater scrutiny of the accounts in order to give an accurate year end forecast

• The 0.5% reserve of £1.7M is also likely to be returned from NHSE which will increase the overall year end surplus

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• The Islington position remains the strongest for the NCL CCGs with Camden forecasting breakeven and Barnet, Enfield and Haringey all forecasting a year end deficit

• For 2018-19 table 7.7 summarises changes in funding and the required QIPP targets based and three different models

• Contracts deadline is scheduled for the end of March and as it stands it is likely that a greater than 3.28% QIPP target will be required

Anthony Browne and Simon Goodwin concluded their update asking if there were any question relating to the report.

• Whilst it was noted that the Islington CCG financial performance was forecast to move into a year-end surplus positon, Lucy de Groot asked for transparency across NCL CCGs and requested the detail for the other forecast positons be shared with members. Simon Goodwin agreed to include this in future reporting

• Karen Sennett indicated that the NICE guidance requiring changes in the process for GPs requesting diagnostics has yet to be implemented and may have had some impact on the level of diagnostic underspend

• Karen Sennett asked when the CCG 2018-19 budget would be finalised. Simon Goodwin explained that values relied upon final contract sign off and agreement of QIPP targets and explained that from a governance perspective, the operating plan and agreed budgets need to be submitted by the end of April and so the intention is to use the 26th April Strategy & Finance committee meeting to review and finalise the operating plan

• Karen Sennett asked how prevention should be included in QIPP plans. Alex Smith explained that there are many QIPP plans and other programmes underway linked to prevention although recognised that much of the savings are longer term and difficult to define. Jo Sauvage asked that the more detailed discussion take place at the QIPP delivery Group and Julie Billett offered to attend to support the discussion. Alex Smith agreed to arrange for Julie Billett to attend the QIPP Delivery Group

• Rathini Ratnavel asked about the ‘no cheaper stock’ issue and the increased cost associated with the overspend. Simon Goodwin reiterated that the increase in costs had impacted the CCG bottom line and as such had reduced the year end surplus

• Katie Coleman noted the comments regarding the £2.1M costs relating to primary care and asked if the detail could be further explained. Anthony Browne explained that this linked to the CCGs agreed underspend against the primary care budget. Katie Coleman asked if this could be made clearer, explaining that Islington CCG had agreed to defer any further spend against for 2017-18 in order to support the NCL positon. Simon Goodwin agreed that for month 11 and 12 that reporting would be much clearer

• Jess McGregor asked about the programme corporate costs and the inclusion of the Healthy London Partnership values. Anthony Browne explained that the full value related to the total London value and that other corporate costs included in the overall figure related to CCG staff and accommodation costs as well as other programme support costs

ACTION: 14/03 - 05 Whilst it was noted that the Islington CCG financial performance was forecast to move into a year-end surplus positon, Lucy de Groot asked for transparency across NCL CCGs and requested the detail for the other forecast positons be shared with members. Simon Goodwin agreed to include this in future reporting. ACTION: 14/03 - 06 Karen Sennett asked how prevention should be included in QIPP plans. Alex Smith explained that there are many QIPP plans and other programmes

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underway linked to prevention although recognised that much of the savings is longer term and difficult to define. Jo Sauvage asked that the more detailed discussion take place at the QIPP delivery Group and Julie Billett offered to attend to support the discussion. Alex Smith agreed to arrange for Julie Billett to attend the QIPP Delivery Group ACTION: 14/03 – 07 Katie Coleman noted the comments regarding the £2.1M costs relating to primary care and asked if the detail could be further explained. Anthony Browne explained that this linked to the CCGs agreed underspend against the primary care budget. Katie Coleman asked if this could be made clearer within the report, explaining that Islington CCG had agreed to defer any further spend against for 2017-18 in order to support the NCL positon. Simon Goodwin agreed that for month 11 and 12 that reporting would be much clearer

3.1.1 The Governing Body NOTED the report. 3.2 Performance Report

All referred to the Performance Report that was circulated ahead of the meeting.

Alex Smith highlighted the following points in the report:

• Met the operational standard of 92% for referral to treatment (RTT) during November and December. On track for the full year performance delivery

• Cancer standards for October all met and six of the eight were met in November. Not met were 62 wait urgent GP referral and 62-day wait screening service. For December the forecast is for seven of eight standards to be met

• A&E performance in November was 90%, 87.7% in December and 87.6% in January, with the year to date performance at 90.5% for Islington CCG

• In the last six weeks Whittington Health has been at 86% and UCLH 83% although there have been days where performance has been significantly lower due to ongoing winter pressures

• Islington A&E Delivery Board will review the increase in ambulance conveyances at Whittington Health and the agreed actions implemented to help manage this, such as the ‘fit to sit’ initiative where new equipment has been purchased and there is an increased focus on ambulatory care

• Ongoing focus on patient flows and the support provided by social services supporting transfer of care

• Mental health beds across London continue to be challenging with significant issues over recent weeks, specifically for female beds

• New LAS performance standards are indicating that for Islington, performance has been better than anticipated with a positive position noted on recruitment

• Community health services reporting is under review with Rachel Lissauer working with the Haringey and Islington CCG Chairs of sub-committees that focus on performance as part of a steering group to consider the options available to improve the activity reporting

• Mental health standards relating to ‘improving access to psychological therapies’ (IAPT) – five of the six standards met. No 12-hour mental health breaches at Whittington Health since the beginning of October 2017 and the recovery suite is scheduled to open in March 2018

Alex Smith concluded his update asking if there were any question relating to his report.

• Rosie Peregrine-Jones reiterated the excellent CQC reports for the trusts previously mentioned

• Karen Sennett asked if, as part of the Performance Report, information on the quality premium and CQUIN information could be included. Alex Smith agreed to review with the Head of Performance, what information could be included

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• Karen Sennett advised members that for Cancer, Islington’s performance across a number of key areas has significantly improved

• Rathini Ratnavel asked how much focus was given to discussing community service performance. Rosie Peregrine-Jones confirmed that at the clinical quality review group (CQRG), specific areas of focus including those within community services were discussed and Rachel Lissauer explained that there was a review taking place of the performance dashboard, looking at routine and urgent performance and to see how this can be improved

• Rathini Ratnaval asked if the e-booking performance information could be included within the Performance Report. Alex Smith agreed to investigate what information was available that could be included.

ACTION: 14/03 – 08 Karen Sennett asked if, as part of the Performance Report, information on the quality premium and CQUIN information could be included. Alex Smith agreed to review with the Head of Performance, what information could be included. ACTION: 14/03 – 09 Rathini Ratnaval asked if the e-booking performance information could be included within the Performance Report. Alex Smith agreed to investigate what information was available that could be included

3.2.1 The Governing Body: 1. NOTED the content of the report

4 Strategy 4.1 Operating Plan – Timetable and Governance

All referred to the report that was circulated ahead of the meeting.

Alex Smith highlighted the key points in the report:

• It was noted that some elements of the paper had already been covered within the meeting

• Key considerations relate to the tight timescales and the proposed method of governance regarding the review and submission of the operating plan

• It was proposed that the April 2018 Islington CCG seminar be used to provide an update on progress to members and that the Strategy and Finance Committee effectively review and sign off the plan on the 26th April 2018 prior to submission on the 30th April to NHSE

• Governing Body members would be invited to the April Strategy & Finance committee in order to review the plan. Karen Sennett also requested and it was agreed that those members unable to attend would be given the opportunity to provide feedback in advance

Alex Smith concluded the update asking if there were any question relating to the report.

• Anthony Browne reiterated that a draft submission had previously been submitted and that the budgets linked to the operating plan continued to be reviewed and scrutinised carefully as part of the preparation for the final submission

• Jo Sauvage reiterated her support for the request for members to attend the April 2018 Strategy & Finance Committee and provide feedback if unable to do so.

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4.1.1 The Governing Body: 1. NOTED the contents of this report and; 2. APPROVED the suggested 2018/19 Operating Plan sign off mechanism

5 Governance and Assurance 5.1 NCL Joint Commissioning Committee Terms of Reference


Helen Pettersen highlighted the key points in the report:

• Noting the main changes to the terms of reference since they were last seen by members

• It was confirmed that the Enfield CCG lay member, Karen Trew continues to Chair the meeting supported by Kathy Elliott, Camden CCG lay member as Vice Chair

Helen Pettersen concluded the update asking if there were any question relating to the report.

• Regarding the changes to the NCL Joint Commissioning Committee ToR, Sorrel Brookes asked if the membership could have roles and not individual names included. Helen Pettersen agreed to feedback the request.

• Deborah Snook asked if the section regarding questions from the public could be reviewed in order to ensure this allowed questions in advance and during the meeting. Helen Pettersen agreed to feedback the comment in order to ensure questions can be asked.

ACTION: 14/03 – 10 Regarding the changes to the NCL Joint Commissioning Committee ToR, Sorrel Brookes asked if the membership could have roles and not individual names included. Deborah Snook asked if the section regarding questions from the public could be reviewed in order to ensure this allowed questions in advance and during the meeting. Helen Pettersen agreed to feedback the comment in order to ensure questions can be asked.

5.1.1 The Governing Body: 1. APPROVED the amended Terms of Reference and Standing Orders of

the NCL Joint Commissioning Committee

5.2 Governing Body Risk Assurance Framework


Alex Smith gave an overview of the risks highlighted within the report and noted the following:

• No new risks have been added to the RAF this month • 434 – re-development of St Pancras Hospital noted and mitigations to

manage associated risk • 205 – Pressure on mental health acute beds risk has been downgraded

given there has been a new psychiatric intensive care unit opened and there have been no further 12 hour breaches

• 409 – 2017-18 QIPP programme delivery has been downgraded given there are significant mitigations in place to achieve the Islington year end budget position

• 423 – Lower Urinary Tract Symptoms (LUTS) risk has been increased to reflect the ongoing challenges and concern raised by local residents at the recent NCL Joint Commissioning Committee

• Two Islington risks were reported as closed • A summary of the three NCL Joint Commissioning Committee risks that

meet the RAF criteria was also provided

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Alex Smith asked members if there were any questions relating to the report. • Deborah Snook asked for clarity regarding the QIPP delivery risk and the

year it referred to. Alex Smith explained that the risk related to the current 2017-18 year and not for 2018-19

• Jo Sauvage noted the LUTS risk increase and reiterated the importance of the service to Islington residents and the desire to achieve an early resolution

• Karen Sennett noted the neurological pathways that are now in place across NCL practices and suggested that these may help alleviate the number of referrals going into the LUTs service although it was recognised that there would continue to be a cohort of patients that value the service

• Katie Coleman noted that the NCL Primary Care Committee risk relating to the Capita contract had remained at the same level and asked if this should be reviewed by the committee. Helen Pettersen explained that the contract is managed by NHSE and as such there is limited ability for us to directly influence mitigations, although she confirmed NHSE are aware that NCL have concerns. It was recognised that the risk would remain on the NCL Primary Care register in order to be monitored by the committee

5.2.1 The Governing Body: 1. NOTED the content of the report

5.3 Minutes of the Quality and Performance Committee The Governing Body referred to the minutes that were circulated ahead of the meeting for assurance.

Karen Sennett noted that the minutes supplied that had been approved by committees were always several months old and asked if it was possible for minutes to be circulated to members prior to the Governing Body so that they were more up to date. Jo Sauvage confirmed that this would be reviewed in order to ensure minutes were available earlier. ACTION: 14/03 – 11 Karen Sennett noted that the minutes supplied that had been approved by committees were always several months old and asked if it was possible for minutes to be circulated to members prior to the Governing Body so that they were more up to date. Jo Sauvage confirmed that this would be reviewed in order to ensure minutes were available earlier.

5.3.1 The Governing Body received ASSURANCE from the minutes. 5.4 Minutes of the Strategy & Finance Committee

The Governing Body referred to the report that was circulated ahead of the meeting for assurance.

There were no comments.

5.4.1 The Governing Body received ASSURANCE from the minutes. 6. For Information The Governing Body noted the minutes for the NCL Primary Care Joint Committee had

been provided for information.

7. Any Other Business 7.1 • No other business noted. These minutes are agreed to be a correct record of the Part 1 meeting of the Islington Clinical Commissioning Group Governing Body held on 9th May 2018. Signed:……………………………………Date:…………………………. Dr Jo Sauvage, Chair, Islington Clinical Commissioning Group

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Meeting Date Action No. Minutes Reference Action Description Responsibility Target Date Progress details

14.03.18 14.03.18 - 01 1.3.1 Jennie Hurley reiterated her request that when the CCG refer to the 'GP Five Year Forward View' that we also include the '10 Point Plan for general Practice Nursing'

All Mar-18 Ongoing

14.03.18 14.03.18 - 02 1.3.1 In respect to the iHub performance review and audit, Lucy deGroot asked that this be noted as an action. ClareHenderson confirmed the review preparation was underwayand that the Strategy and Finance committee would receivea report in June 2018

Clare Henderson

Jul-18 Strategy and Finance Committee to receive the report in June 2018

14.03.18 14.03.18 - 03 1.3.1 Alex Smith to find out from Enfield CCG, if they can provideinformation on the percentage of calls made to 111, as leadcommissioner.

Alex Smith May-18 Enfield CCG have recently asked for an enhanced data set of KPIs which includes this indicator – it will be available from June 2018. Governing Bodies across NCL are in process of approving additional funding for additional clinical triage.

14.03.18 14.03.18 - 04 2.1 Lucy de Groot asked for a summary of the source of funding in relation to the new NCL post for Director of Acute Commissioning.

Simon Goodwin May-18 The summary will be provided to the Governing Body once finalised.

14.03.18 14.03.18 - 05 3.1 Whilst it was noted that the Islington CCG financial performance was forecast to move into a year-end surplus positon, Lucy de Groot asked for transparency across NCL CCGs and requested the detail for the other forecast positons be shared with members. Simon Goodwin agreed to include this in future reporting.

Simon Goodwin May-18 Completed - Reporting will reflect other NCL CCG positon.

Appendix 1.3.1 ACTION LOG: Islington Clinical Commissioning Group Governing Body

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14/03.18 14.03.18 - 06 3.1 Karen Sennett asked how prevention should be included in QIPP plans. Alex Smith explained that there are many QIPP plans and other programmes underway linked to prevention although recognised that much of the savings is longer term and difficult to define. Jo Sauvage asked that the more detailed discussion take place at the QIPP delivery Group and Julie Billett offered to attend to support the discussion. Alex Smith agreed to arrange for Julie Billett to attend the QIPP Delivery Group

Alex Smith May-18 Completed - Julie Billett is attending the QDG on 15th May 2018

14.03.18 14.03.18 - 07 3.1 Katie Coleman noted the comments regarding the £2.1M costs relating to primary care and asked if the detail could be further explained. Anthony Browne explained that this linked to the CCGs agreed underspend against the primary care budget. Katie Coleman asked if this could be made clearer within the report, explaining that Islington CCG had agreed to defer any further spend against for 2017-18 in order to support the NCL positon. Simon Goodwin agreed that for month 11 and 12 that reporting would be much clearer

Anthony Browne

May-18 Completed – Reporting has been amended

14.03.18 14.03.18 - 08 3.2 Karen Sennett asked if, as part of the Performance Report, information on the quality premium and CQUIN information could be included. Alex Smith agreed to review with the Head of Performance, what information could be included.

Alex Smith tbc Completed. Included within GB Performance report

14.03.18 14.03.18 - 09 3.2 Rathini Ratnaval asked if the e-booking performance information could be included within the Performance Report. Alex Smith agreed to investigate what information was available that could be included.

Alex Smith May-18 Completed. Included within GB Performance report

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14.03.18 14.03.18 - 10 5.1 Regarding the changes to the NCL Joint Commissioning Committee ToR, Sorrel Brookes asked if the membership could have roles and not individual names included. Deborah Snook asked if the section regarding questions from the public could be reviewed in order to ensure this allowed questions in advance and during the meeting. Helen Pettersen agreed to feedback the comments in order to ensure the membership is appropriate noted and questions can be asked.

Helen Pettersen May-18 Completed. The current Terms of Reference contain the roles of the members. Schedule 1 to the Terms of Reference contain the names and roles of Committee members. We have the ability in Schedule 1 to change the names of Committee members without the need to formally amend the Terms of Reference at Governing Body meetings. It is important that we retain this so that we have a clear and transparent understanding of who Committee members are.

Questions from the public: In the Committee’s Standing Orders (which form part of the Terms of Reference) there are comprehensive clauses on questions from the public and depositions. In addition, questions from the public is listed as a standing item twice on every meeting agenda. It is listed at the beginning and the end of the agenda so members of the public have the opportunity to ask questions at the beginning and at the end of meetings. In addition, as standard practice the Committee also receives questions in advance of meetings when these are submitted.

14.03.18 14.03.18 - 11 5.3 Karen Sennett noted that the minutes supplied that had beenapproved by committees were always several months oldand asked if it was possible for minutes to be circulated tomembers prior to the Governing Body so that they weremore up to date. Jo Sauvage confirmed that this would bereviewed in order to ensure minutes were available earlier.

Vivienne Ahmad

May-18 The Governing Body will continue to see approved minutes at each meeting. Those members who have asked to receive minutes earlier will receive minutes signed off by the relevant committee Chair in order to ensure they receive them earlier.

10.01.18 10.01 - 04 3.2 Karen Sennett amended the action relating to LAS. It was clarified that this was a request for information regarding the percentage of calls made to 111 that subsequently result in an ambulance conveyance that are assessed by a clinician. Alex Smith agreed to find out from Enfield CCG,if this information could be provided, as lead commissioners.

Alex Smith May-18 Completed - LAS are attending the Haringey GB meeting where further discussion will take place. The request for data will be progressed

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10.01.18 10.01 - 05 3.2 Ian Huckle asked if we could see an average wait time for RTT as this may be more helpful. Alex Smith said that he would review this with his team to see if it could be easily provided. The action was updated at the March meeting to request if some regular data could be added to the performance report.

Alex Smith May-18 Completed - RTT median waiting time information is routinely made available to CCG Performance teams through NELIE. Alex Smith agreed to incorporate some additional detail.

10.01.18 10.01 - 06 3.2 Paul Sinden to consider producing a synopsis of the key areas for Katie Coleman to take to the UCLH Board in her capacity as a new member of the UCLH Board of Governors.

Paul Sinden May-18 The action remains whilst further consideration is given to the completion of an appropriate summary of key areas

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Meeting Date

Action No.

Minutes Reference Action Description Responsibility Target Date Progress details

08.11.17 08.11 - 5 3.2 Governing Body Seminar - Jo Sauvage agreed that it would be helpful to devote some time at a future seminar to focus on the complexities of the CCG finances.

Anthony Browne Jul-18 Diarised

08.11.17 08.11 - 08 Primary Care Delegated Budgets- Deborah Snook asked if spendfor 2016-17/18 along with 2018-19 could be provided in order tocompare spend across the fiveCCGs.

Anthony Browne May-18 Ongoing

14.03.18 14.03.18 - 01.3.1 In respect to the iHubperformance review and audit,Lucy de Groot asked that thisbe noted as an action. ClareHenderson confirmed thereview preparation wasunderway and that theStrategy and Financecommittee would receive areport in June 2018

Clare Henderson Jul-18 Strategy and Finance Committee to receive the report in June 2018

Appendix 1.3.2 ACTION LOG: Islington Clinical Commissioning Group Governing Body AWAITING OUTCOME

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: Wednesday 9 May 2018 TITLE: Accountable Officer Report LEAD GOVERNING BODY MEMBER:

Helen Pettersen - Accountable Officer

AUTHOR: Helen Pettersen - Accountable Officer Tony Hoolaghan - Chief Operating Officer

CONTACT DETAILS:

[email protected]

SUMMARY: This paper provides the Governing Body with an update on key local developments and broader policy areas not otherwise covered on the agenda. This report contributes to:

• Ensuring every child has the best start in life, • Preventing and managing long term conditions to extend both length and quality of

life and reduce health inequalities, • Improving mental health and wellbeing, and • Delivering high quality, efficient services within the resources available.

Prior consideration by Committees and other partners: This paper is for information only Patient & Public Involvement (PPI): This paper is for information only and is available on the CCG website for consideration by patients and the public. Equality Impact Assessment: Not applicable Risks: Not applicable RECOMMENDED ACTION: The Governing Body is asked to:

1. APPROVE the recommendations stated in item 12: Suspension and amendment of standing orders

2. NOTE and COMMENT on the rest of the items in this report. SUPPORTING PAPERS: None

Item: 2.1

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Accountable Officer’s Report

1. Introduction This report will focus on the key activities that the senior team and I have been involved in since the last Governing Body meeting.

2. 360 degree CCG Feedback

i. A survey is carried out every year by Ipsos Mori (on behalf of NHS England) to gauge whether CCGs have strong relationships in place with their local health and care partners. The survey allows a range of stakeholders to provide feedback on their working relationships with the CCG. Stakeholder groups include member GP practices, Healthwatch, the local authority, NHS provider trusts and other CCGs in north central London. The survey is now in its fifth year and the results for 2018 have just been released. I would like to thank all of our stakeholders who took the time to complete the survey. We use the survey responses every year to help us to inform our ongoing organisational development.

ii. Islington CCG has received positive feedback about how we work in partnership with the council and health and wellbeing board. Positive results were also received from the majority of stakeholders who have confidence in the CCG’s ability to commission high quality services. There have been improvements since last year in the majority of the questions asked about how people view the CCG’s leadership.

iii. Member practices’ understanding of the CCG’s finances and how things work could also continue to be developed. Areas of saving and investment are areas highlighted as being of key interest as in previous surveys.

iv. We have already looked at the results with our executive management team, who have made some helpful suggestions about how we could make improvements in certain areas to address the feedback. We will also be looking at the results in detail at our next Governing Body seminar in June. The results will be published on our website for Islington CCG.

3. Public Consultation on the Proposed Redevelopment of the St Pancras Hospital

Site

i. As previously reported to the Governing Body, we have been working closely with Camden CCG, NHS England and other partners (e.g. Healthwatch) on Camden and Islington Foundation Trust proposals to redevelop the St Pancras Hospital site.

ii. On today’s agenda we have the Pre-Consultation Business Case (PCBC) for

approval. The proposals include moving the mental health in patient wards from St Pancras Hospital to a brand new facility at the Whittington Hospital site, as well as developing two new community hubs (one in Camden and one in Islington).

iii. The PCBC is a required document that we must have completed prior to starting the

public consultation. We are planning to hold a special joint Governing Body meeting

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with Camden CCG in late June, where we can sign off the consultation document, consultation methodology, financial modelling and consider the findings of the London Clinical Senate Council review into the clinical case for the proposals. We will also take the consultation documents to the Camden and Islington Health Overview and Scrutiny Committees in mid-June when they will also meet jointly to consider the consultation documents.

iv. The Governing Body will continue to be kept regularly updated on this public

consultation and its findings will come back to the Governing Body for consideration in the autumn.

4. Public Consultation on the Proposed Move of Moorfield’s Eye Hospital and Institute of Ophthalmology In late April 2018 we initiated the governance with Moorfield’s Eye Hospital and NHS England to begin work on a public consultation on a proposal to relocate the Moorefield’s Eye Hospital. This work is at an earlier stage than that reported above for St Pancras Hospital. We aim to adopt much of the learning and good practice from the St Pancras Hospital redevelopment public consultation, and plan to provide a more detailed update on the timetable for this public consultation at the July 2018 Governing Body meeting

5. CSU Transfer Update

i. Governing Body members will recall that we are in the process of transferring a

number of staff from NEL Commissioning Support Unit (NEL CSU) into the NCL CCGs. These staff work mainly on contracts with NHS Trusts (contract monitoring, finance, analytics, clinical quality, performance monitoring etc.). This work is progressing well. Having previously gained Governing Body approval to proceed with this project, and give notice to NEL CSU for some services, we are required to submit a Business Case to NHS England as part of the staff transfer approval process.

ii. The business case was submitted the week of 9th April 2018 and we await feedback on it. We have NCL CCGs’ Governing Body members on the oversight group for this project, and we will continue to keep all Governing Body members updated on progress and confirm the precise transfer date when it is finalised.

6. Contracting

i. The focus of our commissioning and finance teams has been on the 2018/19

contracting round with our acute, community and mental health provider organisations. This is due to be concluded by the end of April, with mediation meetings required for The Whittington Hospital NHS Trust, Royal Free London NHS Foundation Trust (RFL), North Middlesex Hospital NHS Trust and Central London Community Healthcare Trust (CLCH).

ii. The main issue for the acute providers was the financial value of QIPP plans. A

process is therefore being followed during April where clinicians from both parties review these plans again. The aim of this is to ensure all plans have been signed off as clinically appropriate and able to be delivered in year. This will be concluded by the end of April. All other areas, including growth, service developments and

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planning assumptions for the Referral to Treatment target (RTT) have been agreed, subject to reaching overall contract agreement.

iii. A lessons learnt exercise for the 2018/19 contracting round is underway.

7. Finance

i. The focus of the CCG finance team has been year end accounts which have now

closed. Subject to audit process, the CCG has been able to achieve our financial control target for 2017/18.

ii. I would like to acknowledge the hard work and effort of CCG staff during this year of

substantial financial challenge for maintaining financial grip and focusing on delivery of the Quality, Innovation, Productivity and Prevention Plan (QIPP).

iii. The Executive Management team and Governing Body members have been

involved with a substantial amount of planning for transformational priorities in 2018/19 and this work very much continues to be the focus of the CCG at present.

8. Operating Plan

i. The operating plan is one of a number of planning returns (the other significant return being the financial plan) required by NHS England each year and captures a certain set of activity figures and performance trajectories that are used for in year monitoring and assurance. The activity figures have been prepared on the basis of historical trends, contractual negotiations and expected QIPP delivery. This plan has been prepared using the same assumptions as the financial plan. Performance trajectories have been built up in discussion with providers, based on the planning guidance and appropriate STP groups such as the A&E delivery board.

ii. The plan has been signed off by the Strategy and Finance Committee to allow

submission on 30th April in line with national deadlines. Governing body members were invited to attend to provide input.

9. Additional NCL Post

i. At its meeting on 1 March 2018, a recommendation was put forward to the Remuneration Committee in Common for Barnet, Camden, Haringey, Enfield and Islington CCGs to split the role of the Director of Performance and Acute Commissioning, NCL CCGs into two roles. These are a Director of Performance, Planning and Primary Care and a Director of Acute Commissioning.

ii. The Governing Body is asked to note that the Remuneration Committees in Common approved the split of this role into two new posts. Paul Sinden will be the Director of Performance, Planning and Primary Care for the NCL CCGs.

iii. I am pleased to announce the appointment of Eileen Fiori to the post of Director of Acute Commissioning, NCL CCGs. Eileen has a strong provider and contracting background and is a qualified nurse. Eileen has most recently been working at NEL

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CSU as a CSU POD Director and is experienced in leading transformational change. Eileen will start her new role on the 1st May 2018.

10. Information Governance (IG)

i. The IG toolkit process for 2017-18 has been submitted with a self-assessment rating

of satisfactory. This reflects the CCGs ongoing performance of all IG related matters and includes staff training.

ii. The new ‘General Data Protection Regulation’ (GDPR) comes into force on 25th May 2018 and we are working with the CSU and NCL Corporate Services to ensure we meet the required standards and we will be providing governing Body members with some clear information and guidance on this.

iii. In addition, we are also liaising closely with our member practices to provide support

and guidance to aid their preparation in relation to GDPR.

11. Suspension and amendment of standing orders

We would like to make two changes to the CCG Governing Body that are in line with the Standing Orders. The reasons for requiring these proposed changes are summarised as follows:

Quorum of the Governing Body

Following the previous clinical Vice-Chair recently standing down from this role, and becoming a GP non-voting Governing Body member, we need to address potential quorum implications. For the Governing Body to be quorum we need to have at least 3 voting GPs present (excluding the GP Chair). However, our Standing Orders does allow us to make the GP Chair a voting member and whilst we do not have a clinical Vice Chair in place we are proposing that the GP Chair becomes a voting member.

Elected members term length

We are proposing that we use the flexibility our Standing Orders allows to extend the term of elected members to four years (from current two years). The rationale for this is that we are currently bringing our Governing Body Sub-Committees together with those in Haringey CCG. A number of the Islington Governing Body posts are due for re-election in June 2018 and given the current context and the need for continuity in leadership we feel now is not the right time to hold new elections and for the Governing Body membership to potentially change.

The CCG Standing Orders technical details of what is proposed is given below. If Governing Body members approve these proposals we will take them to the CCG Remuneration Committee for final approval and following that we will also notify member practices via the weekly newsletter.

Suspension and amendment of standing orders

i. Suspension

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Further to discussion at the Governing Body seminar in February, it was agreed that we would make some changes to support the ‘working together’ collaboration between Haringey and Islington CCGs, avoiding unnecessary elections and the associated time and costs involved in managing these. This in part results from the Clinical Vice Chair stepping down, reducing voting GP attendance.

With respect to the requirements for a quorum of the Governing Body:

ii. The proposal is to suspend part of Standing Order (SO) 3.6.4(c) such that it will be amended (for the duration of the suspension) from "At least three voting GPs, not including the Chair" to "At least three voting GPs". This has the effect of allowing the Chair to be one of the three voting GPs (so that that number of GPs will be retained in the quorum).

iii. The recommendation is to amend to retain three voting GPs but to include the Chair

iv. Amendment to standing orders

It is also proposed to amend SO 2.2.4(d) to provide that where it is considered appropriate the term of office of an elected member of the Governing Body may be extended so that in those circumstances no election will be called. As part of the amendment, paragraphs (i) and (ii), which concern past years, will be deleted. The proposed amendment is set out below.

a) Subject to paragraph (ii) and SO 2.2.4(e), each elected member of the Governing Body will serve a term of office of four years.

b) Where the Governing Body considers it appropriate to do so, any term of office of an elected member of the Governing Body may be extended by up to two years. The Governing Body should be advised on these matters by the Remuneration Committee.

The recommendation is to amend so that elected members serve a four year term with an option for a two year extension. Current elected members will be eligible for the extension.

Decision Required: The Governing Body are asked to APPROVE the recommendations.

Helen Pettersen Accountable Officer, 9 May 2018

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Item: 3.1 MEETING: Islington CCG Governing Body

DATE: 9th May 2018 TITLE: Finance Report –Month 12 2018/19 Draft Outturn LEAD COMMITTEE MEMBER:

Simon Goodwin, NCL Chief Finance Officer

AUTHOR: Anthony Browne Deputy Chief Finance Officer

CONTACT DETAILS:

[email protected]

SUMMARY: Pending final audit review and opinion, financial performance for the year 2017/18 can be summarised as:

• Islington CCG exceeded the in-year break-even control total by £2.5m and in addition to this, following NHS England instruction, released the 0.5% non-recurrent reserve (£1.7m) and Category M margin return (£0.3m) to its bottom line at Month 12. This is in keeping with figures reported at Month 11 and resulted in the CCG delivering a combined final surplus of £4.5m for the year.

• Requirement to release 0.5% reserve (and the Category M Margin) was announced by NHS England on 20th March 2018 and reported to Committee and Governing Body in Month 11. The conditions set by NHS England meant that this either increased surpluses or improved deficit positions across CCGs in England. For Islington CCG this meant increasing the surplus as set out in the table below.

• In total this increased the CCG’s brought forward surplus from £7.3m to

£11.8m (see table below). The opportunity to access this surplus in future years remains however special approval is required from NHS England. In usual circumstances the right to access this non-recurrent fund is retained for CCGs with lower levels of funding allocation growth and, at present, Islington CCG does not fall in to this category.

Summary of Islington CCG Draft 17/18 Outturn Position (Month 12) £m

Islington CCG In-Year Surplus at Month 12 2.5 Release of the system risk reserve at Month 12 1.7 Category M drug margin rebate return to CCG at Month 12 0.3 Revised in-year surplus at Month 12 4.5 CCG Historic Brought Forward Surplus / (Deficit) 7.3 Revised (RAB) Cumulative Surplus / (Deficit) 11.8

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• Aside from the reserve movements above the CCG reported a £0.7m reduction on in-sector contract costs between the month 11 forecasts and Month 12 draft outturn. This favourable movement is split between the Whittington (£0.3m), UCLH (£0.3m) and Royal Free (£0.2m). The Barts position has remained materially unchanged from previous months.

• The draft Month 12 ‘Agreement of Balances’ reconciliation has informed the final draft position for acute for which there is a £3.2m pressure at year end. As has been the case in previous years this was mainly realised in the UCLH contract (£2.7m). The Whittington Health performed materially to contract however there were additional pressures against Moorfields (£0.2m) and out of sector contracts (Barts £0.9m, Homerton £0.5m and Guys £0.4m). The Royal Free contract finished the year with a £1.1m underspend.

• Overall non-acute services were £1.4m underspent at year end. During the year there had been high profile pressures against Prescribing and although the return of the Category M margin return of £0.3m did see some benefit to the position the NCSO (no cheaper stock) budget pressures resulted in a £0.9m overspend at year end.

• Non-Acute pressures were also seen against Continuing Care (£1.7m) and Learning Disability / Transforming Care budgets lines (£0.7m). Offsetting underspends were seen against the Better Care Fund (see below) and Delegated Primary Care (£2.6m). The latter outturn due to NCL wide risk management of primary care and the remaining headroom following CCG investments in 2017/18.

• Managing the CCG’s overall financial pressure was achieved by:

o Releasing the demand reserve and contingency balance, including an

element of prior year accruals and provisions that were no longer required.

o Freezing investment for part of the Better Care Fund due to non-elective pressures in acute contracting;

o Holding a non-recurrent underspend against the Delegated Primary

Care headroom in 2017/18. This was agreed by Governing Body during the year to balance the NCL Delegated Primary Care position and therefore reduced spend non-recurrently against Islington’s bottom line. The CCG has approved plans to fully commit this headroom in 2018/19.

• As per previous reporting these mitigating items are all non-recurrent and the

2018/19 budget will require delivery of higher than previous QIPP programmes and robust financial management in order to control recurrent cost pressures.

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• During the year Islington CCG also provided direct and indirect support to the

STP and other NCL CCGs in the following ways: o A contribution towards the costs of the STP programme management

office (£0.3m) which was hosted by Islington CCG;

o A contribution to Islington’s share of costs for the NCL Senior Management Team (£0.3m) which was hosted by Islington CCG;

• The CCG’s draft annual report was submitted to NHS England on the 20th

April in accordance with the national timetable. Draft annual accounts will follow on the 24th April which will also see the commencement of the 2017/18 year-end audit. The external auditors (KPMG) are expected to finalise their work around the 15th May with the final 2017/18 audit committee review scheduled for 22nd May. The final draft annual report and accounts need to be signed and sent back to NHS England on the 29th May 2018.

• The Operating Plan is not discussed in detail in this report and a separate presentation is to be provided discussing changes from the first draft submission made on the 8 March 2018. The final submission of the Operating Plan is due back to NHS England on 30th April 2018.

This report contributes to: Delivering high quality, efficient services within the resources available. Prior consideration by Committees and other partners: None specific Patient & Public Involvement (PPI): None specific Equality Impact Assessment: None specific Risks: This report is one element used to monitor the Clinical Commissioning Group’s financial performance in terms of adherence to core statutory duties. RECOMMENDED ACTION: The Governing Body is asked to:

• CONSIDER the draft financial position for Islington Clinical Commissioning Group for the period 1 April 2017 to 31 March 2018.

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Islington Clinical Commissioning Group Finance Report: 1 April 2017 to 31 March 2018 (Month 12 Draft Outturn)

1. INTRODUCTION

1.1 This paper presents to Islington Clinical Commissioning Group’s Governing Body, the financial position for the period to 31 March 2018. This represents the draft unaudited outturn for the CCG for the financial year 2017/18. 2. EXECUTIVE SUMMARY 2.1 Month 12 Draft Unaudited Financial performance for year ending 31 March 2018 can be summarised as follows:

Month 12 Draft Outturn

Budget Actual Variance

£'000 £'000 £'000

Resource Allocation (In-Year) (400,505) (400,505) 0

Acute Contracts (In and Out of Sector) 206,303 209,581 3,278

Other Acute 19,977 19,884 (93)

Acute Commissioning 226,280 229,465 3,185

Mental Health 51,503 51,578 75

Continuing Care 9,289 11,008 1,719

Community Services 21,441 20,638 (804)

Primary Care Prescribing 25,169 26,072 903

Primary Care 6,903 6,372 (530)

PRC Delegated Co-Commissioning 35,408 32,709 (2,699)

NHS 111 2,525 2,732 207

Non-Acute Commissioning 152,238 151,108 (1,130)

Programme Corporate Cost 6,372 6,129 (243)

Running Costs 5,037 4,759 (278)

CCG Reserves (1% NR & 0.5% Contingency) 3,413 0 (3,413)

Acute Demand Reserve 7,165 4,567 (2,598)

In-Year Surplus / (Deficit) 0 4,477 (4,477)

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2.2 The draft unaudited 2017/18 outturn position is reporting Islington CCG exceeding the in-year break-even control total by £2.5m and in addition to this, following NHS England instruction, released the 0.5% non-recurrent reserve (£1.7m) and Category M margin return (£0.3m) to its bottom line at Month 12. This is in keeping with figures reported at Month 11 and resulted in the CCG delivering a combined final surplus of £4.5m for the year.

2.3 Requirement to release 0.5% reserve (and the Category M Margin) was announced by NHS England on 20th March 2018 and reported to Committee and Governing Body in Month 11. The conditions set by NHS England meant that this either increased surpluses or improved deficit positions across CCGs in England. For Islington CCG this meant increasing the surplus as set out above.

2.4 In total this increased the CCG’s brought forward surplus from £7.3m to £11.8m. The opportunity to access this surplus in future years remains however special approval is required from NHS England. In usual circumstances the right to access this non-recurrent fund is retained for CCGs with lower levels of funding allocation growth and, at present, Islington CCG does not fall in to this category.

2.5 Aside from the reserve movements above the CCG reported a £0.9m reduction in acute costs between the month 11 forecasts and Month 12 draft outturn. This favourable movement is split between the Whittington (£0.3m), UCLH (£0.3m) and Royal Free (£0.2m). The Barts position has remained materially unchanged from previous months.

2.6 The draft Month 12 ‘Agreement of Balances’ reconciliation has informed the final draft position for acute for which there is a £3.2m pressure at year end. As has been the case in previous years this was mainly realised in the UCLH contract (£2.7m). The Whittington Health performed materially to contract however there were additional pressures against Moorfields (£0.2m) and out of sector contracts (Barts £0.9m, Homerton £0.5m and Guys £0.4m). The Royal Free contract finished the year with a £1.1m underspend.

2.7 Overall non-acute services were £1.4m underspent at year end. During the year there had been high profile pressures against Prescribing and although the return of the Category M margin return of £0.3m did see some benefit to the position the NCSO (no cheaper stock) budget pressures resulted in a £0.9m overspend at year end.

2.8 Non-Acute pressures were also seen against Continuing Care (£1.7m) and Learning Disability / Transforming Care budgets lines (£0.7m). Offsetting underspends were seen against the Better Care Fund (see below) and Delegated Primary Care (£2.6m). The latter outturn due to NCL wide risk management of primary care and the remaining headroom following CCG investments in 2017/18.

2.9 Managing the CCG’s overall financial pressure was achieved by:

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o Releasing the demand reserve and contingency balance, including an element of prior year accruals and provisions that were no longer required.

o Freezing investment for part of the Better Care Fund due to non-elective

pressures in acute contracting;

o Holding a non-recurrent underspend against the Delegated Primary Care headroom in 2017/18. This was agreed by Governing Body during the year to balance the NCL Delegated Primary Care position and therefore reduced spend non-recurrently against Islington’s bottom line. The CCG has approved plans to fully commit this headroom in 2018/19.

2.10 As per previous reporting these mitigating items are all non-recurrent and the

2018/19 budget will require delivery of higher than previous QIPP programmes and robust financial management in order to control recurrent cost pressures.

2.11 During the year Islington CCG also provided direct and indirect support to the STP and other NCL CCGs in the following ways:

o A contribution towards the costs of the STP programme management

office (£0.3m) which was hosted by Islington CCG;

o A contribution to the cost of the NCL Senior Management Team (£0.3m) which was hosted by Islington CCG;

2.12 The CCG’s draft annual report was submitted to NHS England on the 20th April

in accordance with the national timetable. Draft annual accounts will follow on the 24th April which will also see the commencement of the 2017/18 year-end audit. The external auditors (KPMG) are expected to finalise their work around the 15th May with the final 2017/18 audit committee review scheduled for 22nd May. The final draft annual report and accounts need to be signed and sent back to NHS England on the 29th May 2018.

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3. ACUTE ACTIVITY FINANCIAL PEFORMANCE

3.1. The table below summaries acute in and out of sector contract performance within the draft Month 12 position for 2017/18 for comparative purposes to Month 11 reporting.

Full Year

Month 11 FOT

Forecast Movement

to M12 Budget Actual Variance £'000 £'000 £'000 % In Sector Agreements The Whittington Hospital 100,400 100,386 (14) (0%) 100,686 (300)

UCLH NHS Foundation Trust 69,908 72,575 2,667 4% 72,903 (328)

Royal Free Hampstead NHS Trust 13,216 12,088 (1,128) (9%) 12,302 (214)

Moorfields Foundation Trust 4,392 4,591 199 5% 4,497 94

North Middlesex University 849 826 (23) (3%) 827 (2)

Royal National Orthopaedic Hospital NHS Trust 756 706 (50) (7%) 741 (34)

Great Ormond Street Hospital 473 481 8 2% 467 14

In Sector Total 189,994 191,654 1,660 1% 192,424 (771)

Out of Sector Agreements

Barts and The London NHS Trust 6,266 7,137 872 14% 7,114 24

Homerton University Hospital FT 4,160 4,610 450 11% 4,566 44

Imperial College Healthcare 1,620 1,515 (105) (6%) 1,404 111

Guys and St Thomas FT 2,364 2,772 408 17% 2,856 (83)

Chelsea and Westminster FT 723 527 (196) (27%) 511 16

Kings College Hospital FT 364 451 86 24% 410 41

St George's Healthcare NHS Trust 123 185 62 50% 195 (9)

North West London NHS Trust 258 281 23 9% 310 (29)

Barking, Havering and Redbridge University Hospitals NHS Trust 118 143 25 21%

158 (15)

Royal Brompton FT 184 194 10 5% 192 2

The Royal Marsden NHS FT 130 113 (17) (13%) 108 5

Out of Sector Total 16,309 17,927 1,618 10% 17,821 106

Acute LAS 9,470 9,464 (5) (0%) 9,498 (33)

Total 215,773 219,045 3,272 0% 219,744 (698)

3.2. The table below summarises the Forecast Outturn at PoD level for each of the CCG’s main acute contracts.

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3.3. Month 12 Acute Point of Delivery (PoD) Forecast Variance analysis (£000’s):

UCLH Whittington Health

Royal Free London Moorfields Barts All other

providers Total

Accident and Emergency (118) 226 18 (48) (7) (20) 51 Critical Care 322 (96) (891) 0 218 31 (415) Diagnostic Imaging (373) (394) (77) 9 (33) (38) (906) Drugs and Devices 346 147 139 79 (98) (12) 601 Elective 430 (231) (124) (47) 125 (29) 125 Maternity (186) (777) 3 0 4 96 (860) Non-Elective 2,455 326 (434) 51 492 300 3,189 Outpatients 671 464 140 13 112 49 1,449 Other (880) 321 98 142 59 297 38 2,667 (14) (1,128) 199 872 675 3,272

3.4. The most significant areas of pressure during the year were seen in Non-Elective, followed by Outpatients and drugs and decides. There were material underspends against Diagnostic Imaging, Maternity and Critical Care.

3.5. This same analysis, but by provider, shows that the Whittington realised most pressure against A&E, Non-Elective and Outpatients. At UCLH it is very apparent that there is a significant pressure within Non-Elective with additional over performance in Outpatients and Elective services. Royal Free underspending appears to be driven by reduced levels of spend in Critical Care and Non-Elective. 3.6. Within Out of Sector contracting there is a notable pressure against Non-Elective costs with Barts responsible for the majority of this activity. The Barts position also recorded pressures against Critical Care, Elective and Outpatient services.

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4. NON-ACUTE

Month 12 Draft Outturn Budget Actual Variance £'000 £'000 £'000

Mental Health 51,503 51,578 75 Continuing Care 9,289 11,008 1,719 Community Services 21,441 20,638 (804) Primary Care Prescribing 25,169 26,072 903 Primary Care 5,617 5,120 (497) Delegated Primary Care 35,408 32,709 (2,699) GP Forward View 1,286 1,253 (33) NHS 111 2,525 2,732 207 Non-Acute Commissioning 152,238 151,108 (1,130)

Programme Corporate Costs 6,372 6,129 (243)

Non Acute Total 158,611 157,237 (1,373)

4.1. Non-Acute services were £1.4m underspent at year end. During the year there had been high profile pressures against Prescribing and although the return of the Category M margin return of £0.3m did see some benefit to the position the NCSO (no cheaper stock) budget pressures resulted in a £0.9m overspend at year end. 4.2. Non-Acute pressures were also seen against Continuing Care (£1.7m) and Learning Disability / Transforming Care budgets lines (£0.7m). Offsetting underspends were seen against the Better Care Fund (see below) and Delegated Primary Care (£2.6m). The latter outturn due to NCL wide risk management of primary care and the remaining headroom following CCG investments in 2017/18.

4.3. Note that CCG Running costs reflected a £0.3m underspend against the £5.04m allocation. This was due to a presentational issue with where the Goswell Road to Laycock Street Provision needed to be released back to at the end of the year. 5. CONCLUSION

5.1. Pending final audit review and opinion, the CCG exceeded the in-year break-even control total by £2.5m and following instruction from NHS England released the 0.5% non-recurrent reserve (£1.7m) and Category M margin return (£0.3m) to its bottom line at Month 12. This resulted in a revised final in-year surplus of £4.5m and a cumulative surplus of £11.8m at the end of financial year 2017/18. 5.2. The final outturn position will be confirmed through the annual accounts audit process which commences on 24 April 2018 and is due to be reported to the Audit Committee on 22nd May 2018.

5.3. The Governing Body is asked to:

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• CONSIDER the draft financial position for Islington Clinical Commissioning Group for the period 1 April 2017 to 31 March 2018.

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Appendix page (i) of (iii)

Appendix A - Islington CCG detailed year to date actual (Month 12 2017/18 Draft Unaudited Position)

2017/18 Budget 2017/18 Draft

Outturn Variance Variance £'000 £'000 £'000 %

Allocation In Year (365,097) (365,097) 0 0.0% Historic Underspend (7,295) (7,295) 0 0.0% Delegated Co-Commissioning (35,408) (35,408) 0 0.0% Revenue Resource Limit (407,800) (407,800) 0 0.0%

Acute & Integrated Care NHS SLA - In Sector 189,994 191,654 1,660 0.9% Acute & Integrated Care NHS SLA - Out of Sector 16,309 17,927 1,618 9.9% SLA Exclusions 5,643 4,963 (680) -12.0% Acute Re-admissions & Threshold 150 145 (5) -3.2% Acute LAS 9,470 9,464 (5) -0.1% Acute Planned Care 2,729 3,161 432 15.8% Non Contracted Activity 1,985 2,151 166 8.3% Acute & Integrated Care Total 226,280 229,465 3,185 1.4%

Mental Health 44,970 44,846 (124) -0.3% Mental Health - CAHMS 2,397 1,905 (492) -20.5% Learning Disabilities 4,136 4,827 691 16.7% Continuing Care 9,289 11,008 1,719 18.5% End of Life Care 1,353 1,322 (31) -2.3% Community Services 7,853 7,999 146 1.9% Better Care Fund 11,508 10,753 (756) -6.6% Sexual Health 727 565 (163) -22.4% NHS 111 2,525 2,732 207 8.2% Primary Care - Prescribing 25,169 26,072 903 3.6% Primary Care - Commissioning 610 529 (81) -13.2% Primary Care - LCS 2,200 1,945 (255) -11.6% Delegated Primary Care 35,408 32,709 (2,699) -7.6% Primary Care - GP WIC & Interpreting 1,165 1,201 36 3.1% Primary Care - GPIT 762 648 (114) -15.0%

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Appendix page (ii) of (iii)

Primary Care - Development 880 797 (83) -9.4% GP Forward View 1,286 1,253 (33) -2.6% Non Acute Total 152,238 151,108 (1,130) (1)

London Healthy Living Partnerships 2,539 2,539 0 0.0% Integrated Digital Care Record (IDCR) 11 0 (11) -100.0% Islington & Haringey Wellbeing Partnership 64 131 67 103.9% CSU Contract (Programme) 834 831 (3) -0.4% Property Services (Programme) 371 175 (197) -53.0% Commissioning Support 704 810 106 15.0% Project Management Office 69 55 (14) -20.3% Nursing and Quality 404 235 (169) -41.8% Safeguarding - Adults & Children 329 312 (17) -5.2% Transforming Care Programme 60 55 (5) -8.8% STP Support 986 986 0 0.0% Programme Corporate Costs Total 6,372 6,129 (243) -3.8%

Total Programme Expenditure 384,890 386,702 1,812 0.5%

CCG Running Cost (Excl CSU) Pay 2,300 2,214 (87) -3.8% CCG Running Cost (Excl CSU) Non-Pay 627 746 120 19.1% CCG Running Cost (CSU) 1,853 1,853 0 0.0% CCG Running Cost (PropCo) 257 (54) (312) -121.0% Operating Costs Total 5,037 4,759 (278) -5.5%

Acute Demand Reserve 7,165 4,567 (2,598) CCG Reserves (0.5% Contingency) 1,734 0 (1,734) Non Recurrent Reserve (1%) 1,679 0 (1,679) Reserves and Contingencies Total 10,577 4,567 (6,011)

Total Expenditure 400,505 396,028 (4,477)

Cumulative (Surplus) / Deficit 7,295 11,772 (4,477)

Removal of Cumulative (Surplus) / Deficit (7,295) (7,295) 0

2017/18 Surplus (In-Year) 0 4,477 (4,477)

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Appendix page (iii) of (iii)

Appendix B – Other Acute Point of Delivery (POD) Breakdown Month 12 Reporting (£)

Adjustment Description UCLH Whittington Health Royal Free London Moorfields Barts and London

17/18 ‘Work in Progress’ movement (Maternity, Critical Care) (72,000) (60,949) (294,666) Prior Year Financial Impact (211,391) (16,795) (93,584)

Intermediate Care (Evergreen Ward) 336,174 Neonatal Critical Care - Related Spells 139,872 Claims and Challenges (562,347) 514,649 (45,041) (13,135)

Marginal Rate (703,141) (52,440) 354,024 QIPP STP 101,661 Readmissions to other Providers 48,358 Productivity metrics 125,180 (7,100)

Patient Transport 122,659 Regular Day attendance 45,576 93,780

Ad-Hoc Items (218,693) (28,658)

Patient Transport 38,858

Helicopter Emergency Medical Service (HEMS) 59,710

Other 192,778 (80,398) (22,243) 40,369 9,193

Total (880,055) 320,862 98,359 142,030 59,064

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1

MEETING: Islington Clinical Commissioning Group Governing Body DATE: Wednesday 9th May 2018 TITLE: Performance Report LEAD COMMITTEE MEMBER:

Alex Smith, Director of Planning, Performance & Delivery

AUTHOR: Andrew Broddle, Head of Performance and Planning CONTACT DETAILS:

[email protected]

SUMMARY:

1. Overview The Islington CCG Performance and Quality Summary produced by North East London Commissioning Support Unit (NEL CSU) details performance against constitution targets, locally agreed community targets as well as reporting on national and local quality standards. It should be noted that the performance and quality sections of the report contain different months’ activity, due to the reporting timetable. This is stated as clearly as possible within the report and near-time local intelligence is also included, where relevant.

2. Performance

2.1 ) 18 and 52-Week Referral to Treatment Time (RTT)

Islington CCG met the operational standard (92%) in December 2017 but narrowly missed the standard in January 18 (91.8%) and February 18 (91.9%). In February the 92% standard was missed by just 18 patients from the 16,125 patients treated. The drop in performance has been associated with increased pressure during the winter period bewteen December 17 and February 18 and the proactive delaying of some outpatient appointments agreed across NCL to allow senior clinicians in relevant specialities to better support Emergency Care Departments. The drop in performance has been caused by increased pressure on University College London Hospitals, Whittington Health and the reporting issues at the Royal Free London Hospital which are being addressed by Camden CCG, NHS England and NHS Improvement. The year to date (April 17 – February 18) performance (92.5%) is better than the 92% operational standard. The 52 week wait position at the end of February was that there were no patients who were waiting over 52 weeks for treatment. This is the first month since June 2017 that there have been no patients waiting over 52 weeks for treatment. The charts below show the changes in median waiting times for Islington patients at

Item: 3.2

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Whittington Health (figure 1) and University College London Hospitals (figure 2) since January 2017. While waits have varied over time as of February 2018 the median waiting time at both providers is lower or comparable with year on year figures.

Figure 1: Median Waiting Times: Whittington Health (Islington CCG patients)

Figure 2: Median Waiting Times: University College London Hospitals (Islington CCG patients)

Diagnostics

Islington CCG met the operational standard (of 99%) for the percentage of patients waiting less than 6 weeks for a diagnostic tests continues to meet the operational standard with 99.4% of patients waiting less than 6 week for a diagnostic test in February. The year to date performance is meeting the standard at 99.2%.

2.2 ) Cancer

Islington CCG met four of eight of the national cancer access standards in January 2018, narrowly missing two of the standards (2 week wait – breast symptoms and 31 day wait to first definitive treatment).

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The four standards which were not met in January were; 2 week wait – breast symptoms (92.7% performance against the 93% target) There were three patient choice breaches from a total of 43 cases. 31 day wait to first definitive treatment (95.4% performance against the 96% target) There were three breaches from a total of 65 patients. The breaches were categorised into the following reasons for breach. One patient choice, one extremely complex diagnostic pathway and one due to a capacity issue. 62 day wait urgent GP referral (66.7% performance against the 85% target) There were nine breaches from 27 cases. The nine breaches were categorised into the following reasons for breach. Two were patient choice, one patient was unfit for treatment, three patients were on extremely complex diagnostic pathways, there was a delay in the work up of one patient and two patients did not have complete information on the inter-trust transfer form. University College London had the highest level of breaches of the 62 day wait standard. 62 day wait screening service (83.3% performance against the 90% target) There was one breach from six cases which was due to a complex diagnostic pathway. In total, of the 963 patients from Islington treated for cancer, breast symptoms or suspected cancer in January 2018, 912 (98%) were treated within national waiting time standards. This is an improvement on 97% for December 2017. The NCL Cancer Performance Leadership group meets fortnightly to review sector-wide cancer performance and hold each other to account regarding the achievement of improvement actions. These meetings support the London-wide regulatory process in providing assurance that Trusts and CCGs are taking all necessary steps to improve cancer performance. A number of actions to address the variable 62 day cancer performance are progressing. The UCLH Cancer Vanguard is also providing support. Key improvement actions have been agreed to further develop the urology one stop clinic model and straight to test which will reduce the waiting time for patients.

2.3 ) A&E Islington CCG performance against the 4-hour standard was 87.4% in February and 90.2% for the year to date. Overall 4-hour A&E performance at Whittington Health across February was 86.1%. All Trusts have been under significant pressure during the winter period All CCGs and provider organisations within North Central London are under scrutiny from NHS England and NHS Improvement, as performance has not matched trajectories agreed earlier in 2017/2018 which required 95% performance by March 2018. At the March 2018 A&E Delivery Board a renewed set of priorities were agreed to move the system towards consistently achieving 90% performance within six weeks. This included; • ‘Fit to Sit’ programme to improve ambulance handover times • Maximising the use of Ambulatory Care • Enhancing the Rapid Assessment and Treatment (RAT) model of care • Expanding the Criteria Led Discharge Programme • Further work on improving discharge arrangements between WH and LBI and

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LBH Delayed transfers of care are where patients in acute hospitals are medically fit for discharge but are unable to be discharged. This can be due to delays in social care or when care in a more appropriate healthcare setting is not available. These delays create a poor patient experience and impact on the availability of acute beds for more acutely ill patients. The number of delayed transfers of care has been a continued area of focus by the A&E Delivery Board. The average number of delayed patients per day at Whittington Health has begun to reduce. In January there were average of 11 patients delayed per day which reduced to an average of 8.9 patients per day in February. This is approximately 3% of the bed base at Whittington Health which is lower (better) than the 3.3% target. Daily liaison between the hospital, CCG and Local Authorities continues to resolve obstacles that prevent the transfer of care. There are escalation processes for issues where progress is not being achieved quickly enough involving Director level support from all partner organisations. 2.4) Electronic referrals By 1 October 2018 all NHS Providers need to use e-referral as their only means of making and receiving referrals from GPs to consultant led first outpatient appointments. CCGs and providers are working together in partnership to make the changeover to an electronic only system. The North Central London e-referral Implementation and Steering Group has representation from commissioners and providers and is being chaired by Denise Pettit from Haringey CCG. The Whittington Hospital and North Middlesex Hospitals have paper switch over dates in April, while The Royal Free and University College London Hospitals have switch over dates in August. The latest available published (February) e-referral utilisation data for the Whittington hospital shows it was at 47%. During the last six weeks, intensive efforts have been accelerated to ensure all practices in Islington CCG receive training. NHS England and NHS Digital have been working in partnership with Whittington Health to ensure all suitable clinics are on the e-referrals system. Whittington Health remain on track for an April switch off. However, some services have been jointly agreed between regulators, CCG leads and the Whittington as excluded from e-RS due to alternative pathways being in operation (e.g. MSK) – this impacts on utilisation data as reported by NHS Digital. 2.5) CQUIN As part of the 2017-19 Contract Round, two year CQUINs were agreed with all Providers. For Whittington Health all the CQUINs agreed were National CQUIN’s for Acute and Community Providers as set out in the 2017-19 CQUIN Guidance. As at the end of Quarter 3, Whittington are forecasting delivery of all CQUIN targets other than CQUIN 8: Supporting proactive and safe discharge. The Trust have experienced technical difficulties and so are pushing back implementation of this CQUIN until Quarter 4. Final performance for 2017/18 will be available in July 2018 following validation of Quarter 4 achievement which will take place in June 2018. Figure 3 CQUIN Performance (Quarter 3 2017/18) CQUIN Description Quarter 3

2017/18 Comments

Infections (AMR and Achieved Whittington Health achieved over the 90%

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Sepsis) target for both indicators and in some cases exceeded this target (notably reduction in antibiotic use and early identification of sepsis in clinical settings)

National 4: Improving services for people with mental health needs who present to ED

Achieved The Trusts reviewed progress against Data Quality Improvement Plan (DQIP) and confirmed that systems are in place to ensure that coding of Mental Health via A&E HES data submissions are complete and accurate The patient cohort (people with mental health needs who present to ED) is discussed at frequent attenders meetings with Mental Health team. The coding system for A&E attendances will changing during Q4. A revised plan will be developed once the coding change has been implemented

National 6: Offering clinical advice and guidance

Achieved Data submitted via SDCS portal. Advice and & Guidance covers 35% of activity Timetable and implementation is aligned with the STP

National 7: NHS e-Referrals Achieved 90% of referrals to 1st OP services able to be received through e-RS/on track with agreed trajectory (excluding agreed exclusions)

National 8: Supporting proactive and safe discharge

In progress Whittington Health Trust Management Group have approved late implementation to enable testing, training and downtime of software implementation to be managed in a realistic manner

National 11:Personalised care and support

Achieved Haringey & Islington Community caseloads all had between 90-100% achievement. Generalist community matrons complete a personalised case plan for patients on their caseload (these are patients who have 2 or more long term conditions). The care plan will be shared with GPs and this will be recorded and saved on the patient electronic record (RIO).

2.6) Integrated Urgent Care Service The integrated urgent care (IUC) service for North Central London (NCL) combines NHS 111 and GP out-of-hours’ services into a single integrated service operating a “clinical hub” with GP’s, nurses, paramedics, and pharmacists, to offer direct access to assessment by a clinician, and a broader range of options for advice and treatment. It benefits all residents of Barnet, Camden, Enfield, Haringey and Islington by providing a more responsive model of care which avoids repetition of assessment and unnecessary steps in the patient’s journey. Call waiting times (% within 60 seconds) deteriorated slightly in January and remain below the revised standard of 85%, agreed with Enfield CCG (as lead commissioners) as part of a recovery plan.

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Figure 4: Integrated Urgent Care Service call waiting times

Although the workforce plan is progressing to a planned trajectory, staffing levels still remain below the overall WTE target creating rostering challenges.

2.7) London Ambulance Service (LAS)

LAS handover times Ambulance handover times remain a challenge across London’s hospitals. At the Whittington site 15 minute handover performance worsened from 57.7% in December to 53.6% in January. However, this remains a significant improvement on October performance of 31.4%. The 30 minute handover time was 97.0% in December and 97.1% in January

LAS Ambulance Response Programme (ARP) The new national ambulance response time standards were established under the Ambulance Response Programme Initiative (ARP) led by NHS England. The aim of the ARP is to ensure that:

• The sickest patients receive the fastest response • All patients get the best response allocated to them • No one is left waiting for and unacceptably long time for an ambulance to arrive

Figure 5: London Ambulance performance against the national standards Category Measure National

Standard December January February

1 Mean response time 7 minutes 00:07:24 00:07:09 00:07:28 90th centile 15 minutes 00:12:04 00:11:43 00:11:48

2 Mean response time 18 minutes 00:24:11 00:20:23 00:23:21 90th centile 40 minutes 00:51:11 00:42:05 00:49:20

3 90th centile 120 minutes 02:58:56 02:25:11 02:59:18 4 90th centile 180 minutes 02:51:49 02:19:17 02:34:17

The London Ambulance Service achieved the national standards for category 1 & 4 responses in February. February performance worsened slightly from January, in part due to the adverse weather conditions experienced across London and an increase in call volume across London. The London Ambulance service was ranked fourth of the ten ambulance trusts across England and performed within the England average by 50 seconds. Figure 6: London Ambulance Service performance by STP area February 2018

Q1 Q2 Q3 Q4 Apr May Jun Jul Aug Sept Oct Nov Dec Jan

95.6% 91.0% 91.2% 86.3% 88.3% 81.6% 80.5% 73.3% 77.4% 76.7%

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C1 Mean C1 90th Centile

C2 Mean C2 90th Centile

C3 90th Centile

C4 90th Centile

National Standard

7 minutes

(00:07:00)

15 minutes

(00:15:00)

18 minutes

(00:18:00)

40 minutes

(00:40:00)

120 minutes

(02:00:00)

180 minutes

(03:00:00) North Central

00:07:37

00:12:24

00:24:31

00:51:25

03:42:28

03:17:46

North East

00:07:45

00:11:50

00:25:45

00:54:23

03:14:55

02:49:53

North West

00:07:34

00:11:47

00:23:51

00:51:18

03:12:56

02:42:06

South East

00:07:14

00:11:33

00:19:55

00:40:43

02:18:08

02:06:48

South West

00:06:35

00:11:27

00:21:56

00:45:05

02:36:10

02:01:38

2.8) Whittington Health (WH) Community Health Services (CHS)

The new performance report for Community Services has been included within the P&Q report. This breaks down waiting time by ‘routine’, ‘urgent’ and ‘average’. It showed that six of 30 services saw 95% of patients within target for routine services. Key highlights include:

• The podiatry service increased the number of patients meeting the routine target of six weeks from 24.8% in January to 53% in March 2018

• The Bladder and Bowel adult service increased the number of patients meeting the routine target of twelve weeks from 54.8% in January to 72% in March 2018

Regular reports to the Islington Quality and Performance Committee are being made regarding the work of the Community Service Improvement Group which aims to improve performance standards. 2.9) Metal Health Standards Islington CCG met five of the six Improving Access to Psychological Therapies targets for the last reporting period. These were;

• The proportion of patients on CPA who were followed up within 7 days after discharge from psychiatric inpatient care.

• The proportion of admissions to acute wards that were gate kept by the CRHT teams.

• The percentage of RTT first episode psychosis (FEP) periods within 2 weeks of referral.

• The dementia diagnosis rate (Age 65+). • Patients on a care programme approach who were followed up within 7 days of

discharge from psychiatric inpatient care The standard which was narrowly missed was the proportion of children and young people with eating disorders (routine cases) that wait 4 weeks or less from referral to start of NICE-approved treatment. Performance in quarter 3 was 87.50% against the standard of 95%.

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CIFT did not meet the standard in September of beginning 95% of mental health assessments within 1 hour within A&E departments at the Whittington, UCLH and the Royal Free (Performance was 88.6%, 86.2% and 91.9% respectively). CIFT did not meet the standard in September of beginning 95% of mental health assessments within 24 hours on wards at the Whittington (82.1%) or UCLH (90%) There have been no 12 hour mental health breaches at Whittington hospital since the beginning of October. . The new recovery lounge is due to open in the coming six weeks which will provide a better therapeutic environment for patient’s in a crisis. 2.10) Continuing Health Care Figure 7: Percentage of decision support tool (DST) assessments carried out in an acute setting Period Number of DSTs

carried out Number of DST carried out in an

acute hospital setting

% of DST carried out in an acute hospital

setting Quarter 1 28 1 4% Quarter 2 25 4 16% Quarter 3 29 7 24% Quarter 4 30 8 27%

The target for the percentage of Decision Support Tool (DST) assessments carried out in an acute setting is 15%. Two of the assessments in the acute setting in February were at hospitals which fall outside of our catchment area (one of the assessments was undertaken at Homerton Hospital and the other one was undertaken at the Royal London Hospital). The two hospitals have subsequently been contacted to discuss how CHC assessments in their settings can be avoided in the future for Islington patients. Two of the four assessments in March were completed in the acute setting as part of existing reviews. The target is that 80% of standard continuing health care referrals are completed within 28 days. Figure 8 shows that Islington met this standard in Quarter 2, 3 & 4. Figure 8: Percentage of continuing health care referrals are completed within 28 days.

2.11 Quality Premium The Quality Premium (QP) is intended to reward CCGs for improvements in the quality of the services which they commission and for associated improvements in reductions in inequalities in access and in health outcomes. The QP award will be based on measures

Period Standard CHC referrals

completed

Number of referrals completed within 28

days

% Standard CHC referrals completed

within 28 days Quarter 1 64 14 21% Quarter 2 23 19 83% Quarter 3 41 33 80% Quarter 4 32 29 91%

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that cover a combination of national and local priorities and will reflect the quality of the health services commissioned. The total value of the quality premium in 2017/18 was £1,145,905

The Quality Premium paid in 2018/19 will be based on the performance for 2017/18.

There were five national measures (early cancer diagnosis, GP access and experience, continuing healthcare, bloodstream infections and mental health) and two local measures (one of which is the mental health measure and the other is the expected prevalence of chronic kidney disease).

These measures are:

1. For CCGs to show an improvement in early cancer diagnosis (increase proportion diagnosed at stages 1 or 2)

2. That the GP survey indicates 85% of respondents said that they had a good experience of making an appointment or that there was a 3 percent increase (between July 17 and July 18 survey results)

3. For CCGs to ensure that in more than 80% of cases with a positive NHS Continuing

Health Care (CHC) assessments took place within 28 days, and that less than 15% of all NHS Continuing Health Care assessments take place in an acute hospital.

4. For CCGs to demonstrate they are reducing Gram Negative Bloodstream Infections (GNBSIs) and inappropriate antibiotic prescribing in at risk groups

5. For CCGs to demonstrate a reduction in the number of out of area mental health placements

The final data has not yet been confirmed for 2017/18. However, early indications are that at least three of the national improvement measures have not been met (early cancer diagnosis, overall experience of making a GP appointment, CHC assessments). Data for reductions in gram negative bloodstream infections and inappropriate antibiotic prescribing is still awaited.

The value of the quality premium paid will be reduced by 25% for each of the constitutional measures which are not met. The constitutional measures are: The 18 week referral to treatment pathway; A&E four hour waits; the 62 day cancer waiting standard (urgent GP referral to first definitive treatment) and LAS performance for category A, red 1 ambulance calls. Of the four constitutional measure the latest data for 17/18 shows that at least three of these standards were not met. The only standard which may have been met when final data is published will be the 18 week referral to treatment pathway standard. This means that the payment any of the national or local measures which were met will be reduced by 75%.

The current estimate of the likely quality premium payment is £129,596.

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This report contributes to:

• Delivering high quality, efficient services within the resources available. Prior consideration by Committees and other partners: not applicable Patient & Public Involvement (PPI): not applicable Equality Impact Assessment: not applicable Risks: not applicable RECOMMENDED ACTION: Islington Clinical Commissioning Group Governing Body is asked to:

• Note the report SUPPORTING PAPERS:

• Islington CCG Performance and Quality Summary April 2018

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Islington CCG Performance and Quality Summary

April 2018

Appendix 3.2.1

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Item Page

Islington CCG Performance and Quality Summary & Dashboards 3 - 6

Whittington Health NHS Trust Performance and Quality Summary 7 - 26

Moorfields Eye Hospital NHS Trust Performance and Quality Summary 26 - 34

Camden & Islington NHS Foundation Trust Performance and Quality Summary 35 - 47

University College London Hospitals NHS Foundation Trust Performance and Quality Summary

48 - 69

NCL Integrated Urgent Care Services Summary 70 - 72

London Ambulance Service Summary 73 - 75

Quality Assurance Sign-off 76

Contents

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Executive Dashboard

Key:PerformancePerformance is above TargetPerformance is below TargetNo Target

Arrows indicate improvement or deteriorating performance on the

previous month

Notes:* Latest CCG data is provisional and unpublished.** Moorfields only recorded activity for three cancer waiting time pathways in January 2018, and similarly Whittington Health NHS Trustittington Health NHS Trust recorded activity against six.

18 Weeks RTT Admitted and Non-Admitted Standards have been abolished, and the Incomplete Pathways Standard has become the sole measure of patients’ constitutional right to start treatment within 18 weeks.

ARP = Ambulance Response Programme

3

Performance Overview

RTT Admitted < 18 Weeks* Feb-18 80.3% Jan-18 80.3% 84.9% 74.8% 80.8% -

RTT Non-Admitted < 18 Weeks* Feb-18 91.6% Jan-18 90.1% 90.4% 88.6% 94.0% -

RTT Incomplete < 18 Weeks* Feb-18 91.9% Jan-18 92.1% 91.0% 83.0% 94.0% 92%

Diagnostic Tests < 6 Weeks* Feb-18 0.6% Jan-18 99.0% 99.1% 99.3% 100.0% 99%

Cancer Standards Met (Total 8 Standards) Jan-18 4 Jan-18 5 2 6 3 -

IAPT - % Waited less than 6 weeks for a course of treatment (Islington CCG at C&I) Dec-18 88.0% 75%

IAPT - % Waited less than 18 weeks for a course of treatment (Islington CCG at C&I)

Dec-18 98.0% 95%

A&E 4 Hour Waits* Feb-18 87.4% Feb-18 86.1% 86.0% 86.5% 99.3% 95%

CAT 1 ARP 7 mins (London Wide LAS) - Mean

Feb-18 00:07:26 ##### 00:07:00

CAT 1 ARP 15 mins (London Wide LAS) - 90th Centile

Feb-18 00:11:48 00:15:00 00:15:00

CAT 2 ARP 18 mins (London Wide LAS) - Mean

Feb-18 00:23:21 00:18:00 00:18:00


Feb-18 00:49:21 ##### 00:40:00


Feb-18 02:59:27 ##### 02:00:00


Feb-18 02:34:17 ##### 03:00:00

Ambulance Handover 15 Mins Feb-18 52.8% 35.6% 35.2% n/a 100%

Ambulance Handover 30 Mins Feb-18 96.9% 83.4% 85.9% n/a 100%

Reporting Month

Reporting Month

TrajectoryIslington CCG

Whittington MoorfieldsRoyal FreeUCLH Target

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Islington CCGPerformance and Quality Summary

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Key Messages

CCG Performance - This slide is a brief summary of the overall CCG position – for more detail on each provider see the relevant Provider Slides.

Accident and Emergency

Islington CCG performance against the four hour waiting time indicator in January 2018 was 87.4%.

The main providers for Islington patients performed as below for February 2018:Whittington Health NHS Trust 86.1% University College London Hospitals NHS Foundation Trust 86.1% Royal Free London NHS Foundation Trust Hospitals 86.5%

All CCGs and provider organisations within North Central London are under scrutiny from NHS England and NHS Improvement as performance has not matched trajectories agreed earlier in 2017/2018 which predicted 95% performance by March 2018.

The Islington A&E Delivery Board Improvement Plan is under regular review and at the March 2018 A&E Delivery Board a renewed set of priorities were agreed to move they system towards 90% performance. The A&E Delivery Board Meeting in March 2018 identified increased numbers of patients presenting to A&E, the increased clinical needs of the patients presenting to A&E and to GP surgeries, the increased complexity of the needs of patients being discharged from hospital as factors contributing to A&E four hour wait performance being less than predicted.

Cancer

Islington CCG met four from the eight national cancer access standards in January 2018. The standards missed were:• Two week wait symptomatic breast referrals – three patient choice breaches from a total of 43 cases led to a performance of 92.7%

against the 93% standard.• 31 day diagnosis to treatment – three breaches from a total of 65 patients one of which was patient choice, one clinical and one due to

administrative delays – led to a performance of 95.4% against the 96% standard.• 62 day urgent GP referral to treatment – nine breaches from 27 cases to give a performance of 66.8%. Six of the breaches were due to

patient choice or clinical reasons and three due to administrative or capacity delays.51 of 186


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Key Messages

Cancer (continued)

• 62 day screening to treatment – one breach from six cases which was due to complex clinical reasons led to a performance of 83.3% against the 90% standard

In total, of the 963 patients from Islington treated for cancer, breast symptoms or suspected cancer in January 2018, 912 ( 98%) were treated within national waiting time standards. This is an improvement on 97% for December 2017.

In summary – Islington CCG performance on cancer access times improved overall but due to the small number of patients treated in specific areas four individual treatment targets were missed.

Mental Health Indicators

Islington CCG met all of the following standards for mental health access for the last relevant reporting period:• Dementia Diagnosis Rate for February 2018• First Episode of Psychosis for February 2018• Gatekeeping of acute admissions by Crisis Resolution Home Treatment teams (CRHT) for Quarter Three 2017/2018• Care Programme Approach patients followed up within seven days of discharge for Quarter Three 2017/2018

The urgent referral waiting time standard for Children and Young People with Eating Disorders was met in Quarter 3 2017/2018 but the routine waiting time standard of 95% of patients seen within four weeks was not met with the CCG performance at 87% as three from 24 patients waited longer than four weeks to be seen.

Quarter Three Improving Access to Psychological Therapies data for Islington CCG shows a recovery rate of 47% which is below thestandard of 50%. However, the most recent local monthly data shows the recovery rate has improved in January and February 2018 and Camden and Islington NHS Foundation Trust predict compliance with the 50% standard by the end of Quarter four.

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6

Key Messages

Referral to Treatment and Diagnostics Provisional data for February 2018 indicates that Islington CCG performance against the 18 week Referral to Treatment target was 91.9% against the 92% target. The overall Islington CCG 18 week Referral to Treatment standard was missed by 18 patients from a total of 16,125:• Whittington Health (which accounts for 35% of all Islington patients on Referral to Treatment pathways) failed the standard for Islington by

65 patients while achieving the standard for all CCGs. • University College London Hospitals (which accounts for 40% of all Islington patients on 18 week pathways) achieved the standard for

Islington patients but failed to achieve the standard for all CCGs.• Royal Free London Hospital (which accounts for 8% of all Islington patients on Referral to Treatment pathways) missed the standard for

Islington by 104 patients and failed to achieve the standard for all CCGs.In summary, assuming provider trusts are not deliberately treating patients differently depending on their CCG of origin, the fact that Islington CCG has not met the 18 week Referral to Treatment Standard for the last two months is probably due to the increased pressure on University College London Hospitals and Whittington Health generally (as reflected across national performance) in meeting Referral to Treatment standards and the particular problems experienced by Royal Free London which are being addressed by Barnet CCG and NHS England and NHS Improvement.

The charts below show the changes in median waiting times for Islington patients at Whittington Health and University College London Hospitals over the 14 months to February 2018. While waits have varied over time as at February 2018 median waiting time was lower for both providers than at January 2017.

At CCG level 99.4% of patients were waiting less than six weeks for a diagnostic test at the end of February 2018 which is compliant with the national standard. 53 of 186

Islington CCG Performance and Quality Dashboard

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Notes:• Latest CCG data is provisional and unpublished.

A&E A&E All Types Performance 88.9% 89.7% 91.5% 92.6% 92.7% 91.4% 90.8% 90.1% 90.3% 90.0% 87.7% 87.6% 87.4% 90.2%

18 Weeks RTT Admitted * 85.3% 84.6% 83.9% 84.6% 86.0% 81.3% 84.1% 82.4% 82.5% 84.9% 83.0% 86.0% 80.3% 83.6%

18 Weeks RTT Non-Admitted * 92.5% 94.1% 93.8% 93.9% 93.6% 91.9% 91.9% 92.3% 92.7% 91.2% 92.5% 92.0% 91.6% 92.5%

18 Weeks RTT Incomplete Pathways * 93.4% 93.6% 93.5% 93.4% 93.0% 92.2% 92.1% 92.1% 92.6% 92.7% 92.3% 91.8% 91.9% 92.5%

RTT >52 week waits Incomplete * 0 0 0 1 0 1 8 5 2 3 2 2 0 24

6 Weeks Diagnostic Waits * 0.2% 0.3% 0.6% 1.0% 0.9% 0.98% 0.99% 0.86% 0.70% 0.49% 0.89% 0.49% 0.57% 0.8%

2 Week Cancer Wait 96.7% 95.4% 92.9% 94.5% 96.7% 96.3% 93.8% 94.1% 95.1% 96.1% 96.9% 95.3% 95.2%

2 Week Cancer Wait:Breast Symptoms 94.4% 95.8% 93.6% 94.6% 95.9% 97.7% 98.3% 98.1% 95.7% 98.2% 96.6% 92.7% 96.2%

31 day Cancer Wait:1st definitive treatment 97.7% 97.2% 98.3% 96.8% 95.1% 100.0% 100.0% 95.2% 100.0% 97.3% 97.9% 95.4% 97.6%

31 Day Cancer Wait: Subsequent treatment (Surgery) 100.0% 100.0% 100.0% 100.0% 100.0% 91.7% 100.0% 84.6% 100.0% 100.0% 100.0% 100.0% 96.6%

31 Day Cancer Wait: Subsequent treatment (Chemotherapy) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

31 Day Cancer Wait: Subsequent treatment (Radiotherapy) 94.7% 100.0% 100.0% 95.2% 92.9% 100.0% 100.0% 95.5% 100.0% 100.0% 100.0% 100.0% 98.5%

62 Day Cancer Wait: GP Referral 94.7% 65.4% 70.0% 92.6% 83.3% 85.2% 88.5% 85.7% 88.2% 80.6% 85.0% 66.7% 82.5%62 Day Cancer Wait: Screening service 100.0% 100.0% 100.0% 66.7% 50.0% 83.3% 85.7% 100.0% 81.8% 85.7% 83.3% 81.8%62 Day Cancer Wait: Consultant Upgrade 100.0% 100.0% 80.0% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0% 88.9% 100.0% 100.0% 93.5%

MRSA reported infections 2 0 0 0 2 0 0 0 0 1 2 0 5

C. Difficile reported infections 4 4 3 7 5 7 5 4 8 2 4 6 51

Mixed Sex Accommodation (MSA) (Number of breaches) 2 3 3 2 5 3 9 4 4 12 4 7 2 55

Apr-17 May-17 Jun-17 Jul-17 Oct-17Theme KPI / Measure

Qu

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2017-18 YTDAug-17 Sep-17 Nov-17 Dec-17 Jan-18 Feb-18Mar-17Feb-17

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Key Messages

Accident and Emergency

• Whittington Health NHS Trust A&E four hour performance has been between 86.1% and 86.5% each month from December 2017 to February 2018.

• Performance was predicted to be 92% in February and reasons why performance has not been as predicted include increased cases ofinfluenza, increased admissions in the over 75’s, increased ambulance presentations and increased numbers of complex discharges

• All of the above point to an increased acuity and complexity of cases Whittington Health NHS Trust which put pressure on acute and community capacity

• All A&E Delivery Board winter schemes are under regular review by the A&E Delivery Board. Progress on all these schemes is reviewed at the A&E Delivery Board and fortnightly calls with NHS England and NHS Improvement.

Referral to Treatment Time and Diagnostics

The percentage of patients waiting less than 18 weeks for treatment remains above the operational standard of 92% for January 2018. Whittington Health achieved the 99% of patients waiting less than six weeks for a diagnostic test in January 2018 but due to a reporting error by Whittington Health this is not reflected in the published data. At the end of January 2018 no patients were waiting over 52 weeks for treatment at Whittington Health while the number of patients waiting more than 18 weeks for treatment has remained fairly constant since September 2017.

Cancer ServicesWhittington Health met all of its cancer access waiting time standards for January 2018 apart from the 62 day urgent GP referral to treatment target which was missed by 3% or one patient from 23 cases. The small number of cases seen by Whittington Health mean their performance can be significantly affected by small variations in numbers of patients attending or choosing to delay appointments.

Community ServicesPA Consulting have been appointed by the Haringey and Islington Wellbeing Board to undertake a defined piece of project work with regard toWhittington Community Services to conclude in May 2018.The remit of the programme includes:• Review of current service provision• Format of performance reporting• Recommendations for future strategy

Based on current reporting overall Community Service waiting times have remained fairly constant between December 2017 and January 2018 apart from a significant improvement in District Nursing waiting times where of patients where over 90% of patients were seen within agreed waiting times.

Whittington Health NHS TrustProvider Key Messages

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Whittington Health NHS Trust Performance Dashboard

9

18 Weeks RTT Admitted - 80.27% 73.07%

18 Weeks RTT Non-Admitted - 90.15% 89.74%

18 Weeks RTT Incomplete Pathways 92% 92.10% 92.16%

>52 week waits Admitted - 0 2

>52 week waits Non Admitted - 0 0

>52 week waits Incomplete 0 0 5

6 Weeks Diagnostic Waits 1% 1.01% 0.92%

Cancelled Operations (2017-18 Q3) 100% 100.00% 97.33%

2 Week Cancer Wait 93% 94.89% 94.64%

2 Week Cancer Wait:Breast Symptoms

93% 97.92% 97.97%

31 day Cancer Wait:1st definitive treatment

96% 100.00% 100.00%

31 Day Cancer Wait: Subsequent treatment (Surgery)

94% 100.00% 100.00%

31 Day Cancer Wait: Subsequent treatment (Chemotherapy)

98% 100.00% 100.00%

31 Day Cancer Wait: Subsequent treatment (Radiotherapy)

94%

62 Day Cancer Wait: GP Referral

85% 82.22% 87.53%

62 Day Cancer Wait: Screening service

90% 100.00%

62 Day Cancer Wait: Consultant Upgrade

- 100.00% 96.00%

KPI/ThresholdTHE WHITTINGTON HOSPITAL NHS

TRUSTJan-18 YTD


TRUSTJan-18 YTD

A&E All Types Performance 95% 86.10% 90.06%

No of waits from decision to admit to admission (Trolley waits - over 12 hours)

0 0 24

% Ambulance Handovers within 15 mins: KPI 1 100% 52.80% 41.40%

% Ambulance Handovers within 30 mins: KPI 2 100% 96.90% 97.40%

Number of Ambulance Handover - 30 minute breaches 0 37 326


% Patient Records Captured Electronically: KPI 4 90% 92.70% 91.40%

KPI/Threshold

THE WHITTINGTON HOSPITAL NHS TRUST


TRUSTFeb-18 YTD

Feb-18 YTD

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10

Whittington Health NHS TrustQuality and Performance Dashboard

Community Services

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Whittington Health NHS TrustQuality and Performance Dashboard

Community Services

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Whittington Health NHS TrustQuality Dashboard

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Theme KPI/Measure Reporting Period Actual YTD Current Month and Previous Month's Trend

Blue = Actual Red = Target

SHMI rate - rolling 12 month average (received quarterly)

Jul 2016 - Jun 2017 72.6

Proportion of Patients New Pressure Ulcers(Safety Thermometer) Feb-18 7 65

Proportion of Patients Falls With Severe Harm (as per NPSA definition - Safety Thermometer) Feb-18 0 0

Number of Never Events Feb-18 0 1

Serious Incidents (SIs) Reports Submitted Feb-18 1 34

Number of MRSA Bacteraemia Jan-18 0 3

Number of Clostridium Difficile Jan-18 0 12

Mandatory Training rate Jan-18 81%

Average fill rate - Registered nurses/midwives (Day) Jan-18 79%

Average fill rate - Registered nurses/midwives (Night) Jan-18 89%

Average fill rate - Care staff (Day) Jan-18 131%

Average fill rate - Care staff (Night) Jan-18 148%

Patient Safety

70.8 72.6

26 7

36 6 7 4 7

0 0 0 0 0 0 0 0 0

4 36

24

20

71

21

31

2 31

0 0

1

0 0 0 0 0 0

87% 86% 87% 86% 80% 85% 81% 81% 79%

94% 92% 92% 92% 103% 96% 91% 92% 89%121% 111% 114% 111% 123% 133% 130% 136% 131%

124% 118% 128% 114% 137% 146% 144% 130% 148%

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Whittington Health NHS TrustQuality Dashboard



VTE - % patients who have had a VTE assessment within 24 hours of admission Dec-17 95.2% 95.7%

Cancelled operations - Number of patients not treated within 28 days of last minute elective cancellation 2017-18 Q3 0 2

Overall Maternity - C-Section rate (Trust Data) Feb-18 33.6%

Friends & Family test (FFT) - % Recommend Inpatients Jan-18 96.5%

Friends & Family test (FFT) - Response Rate % Inpatients Jan-18 17.4%

Friends & Family test (FFT) - % Recommend A&E Jan-18 81.9%

Friends & Family test (FFT) - Response Rate % A&E Jan-18 12.8%

Maternity Friends & Family test (FFT) - Question 1 % Recommend (Antenatal Care) Jan-18 96.9%

Maternity Friends & Family test (FFT) - Score Question 2 % Recommend (Birth) Jan-18 97.6%

Maternity Friends & Family test (FFT) - Score Question 3 % Recommend (Post Natal Ward) Jan-18 93.6%

Maternity Friends & Family test (FFT) - Score Question 4 % Recommend (Post Natal Community Provision) Jan-18 98.0%

Friends & Family test (FFT) - % Recommended Outpatients Jan-18 93.8%

Friends & Family test (FFT) - Response Rate % Outpatients Jan-18 2.4%

Staff Friends & Family test (FFT) - % Recommended as a place to work 2017-18 Q2 53.3%

Staff Friends & Family test (FFT) - % Not Recommended as a place to work 2017-18 Q2 34.2%

Staff Friends & Family test (FFT) - % Recommended as a place for Care 2017-18 Q2 69.4%

Staff Friends & Family test (FFT) - % Not Recommended as a place for Care 2017-18 Q2 13.0%

Friends & Family test (FFT) - % Recommended Community Jan-18 95.4%

Friends & Family test (FFT) - Response Rate % Community Jan-18 2.8%

Mixed sex Accommodation - Breaches Feb-18 0 0

Complaints - Number of formal complaints (Trust data) Feb-18 21 284

Clinical Effectiveness

Patient experience

2

0 0

94%97% 96% 95%

98% 98% 98% 97% 97%

23% 20% 21% 15% 16% 18% 18% 16% 17%

16% 14% 13% 14% 13% 13% 12% 12% 13%

95% 89% 97% 93% 96% 96% 97% 98%

81% 80% 84% 84% 86% 92% 93% 94%

100% 98% 98%94% 97% 100% 100% 98%

54%53%

95% 95% 96% 95% 97% 96% 95% 96% 95%

13%13%

32% 34%

69% 69%

90%100% 97% 100% 96% 100% 99% 97%

87% 84% 85% 83% 80% 82% 83% 83% 82%

95% 94% 95% 97% 96% 95% 95% 96% 95%4% 3% 4% 3% 3% 3% 2% 2% 3%

25% 31% 28% 27% 33% 37%28% 34% 34%

3.60% 3.14% 2.80% 1.93% 2.47% 3.25% 3.40%1.91% 2.39%

93% 94% 93%91% 91% 93% 92% 92% 94%

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Area Current Position/Risks Mitigating ActionsCurrent level of

Assurance / Recommendations

Accident & Emergency

Published performance against the four hour A&E target at Whittington Health was 86.1% in February 2018. From December 2017 to February 2018 performance has been around 86%.

There are two factors impacting on the A&E performance:• Flow through the A&E Department• Flow through the hospital to allow admissions

from the A&E Department

In both areas performance has not been as predicted because of:• Increased A&E attendances• Increased acuity of attendances (as reflected

by the number of occasions when the A&E resuscitation area is full)

• Increased complexity in medical management of patients admitted (as reflected in the increase in numbers of patients admitted for more than seven days)

• The continuing impact of influenza (consistently 20 beds occupied by patients with a confirmed laboratory diagnosis of flu)

The Islington Discharge to Assess Programme has delivered or exceeded its trajectory for Pathways One, Two or Three for February 2018

Daily liaison between Whittington Health, CCG and Local Authorities takes place to resolve obstacles leading to delays to discharges.

Weekly Multi-Agency Discharge Events (MADE) are held at Whittington Health to facilitate improved discharge flows.

A recent review of the Islington A&E Delivery Board Improvement Plan identified the following areas for increased focus:

• Maximising rapid assessment and treatment utilisation

• Increasing Ambulatory Care presence in the Emergency Department

• Renewed focus on criterial led discharge

• Maintaining good ambulance handover performance through ‘fit to sit’

A comprehensive A&E Delivery Board Improvement Plan incorporating actions from primary, community, acute mental health and social care providers is updated monthly and reviewed at A&E Delivery Board.

Continued monitoring of performance at Contract Management Group and quality and safety implications of performance at Clinical Quality Review Group.

Whittington Health NHS TrustPerformance & Quality Summary

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Area Current Position/Risks Mitigating Actions Current level of Assurance/Recommendations

Cancer In January 2018, Whittington Health achieved all relevant national cancer waiting time standards apart from the 62 day urgent GP referral to treatment standard. This standard was missed by one case from a total of 23. In all four cases breached the standard: two due to patient choice or clinical reasons, one due to internal delays at Whittington Health and one due to inter-trust referral delays.

Low numbers of cases at Whittington Health mean that statistically insignificant variations in performance due to patient availability or complexity have a disproportionate impact on Whittington Health performance.

At specialty level upper and lower gastroenterology are the only areas failing to meet the two week wait urgent general practitioner referral to appointment standards.

Data for January 2018, shows that two from five onward referrals from Whittington Health were made within 38 days of the original referral being received.

Remedial measures to address the clinical and administrative challenges to gastroenterology and endoscopy services around two week waits reported earlier in the year have improved performance in this area from 39% in April 2017 to 87.2% for lower gastroenterology and 73.5% for upper gastroenterology for January 2018.

Whittington Health predicts full compliance with all two week wait specialties in March 2018.

Root cause analyses for all patients waiting longer than 62 days from referral to treatment are considered at the Clinical Quality Review Group

Recommend monitoring of performance through Contract Monitoring Group, quality and patient safety implications of performance through Clinical Quality Review Group and application of contractual levers if appropriate.

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Referral to Treatment Time and

Diagnostics

Whittington Heath met the headline 18 week incomplete referral to treatment standard for January 2018 with 92.10% of waiting patients waiting less than 18 weeks.

No patients were identified as waiting more than 52 weeks for treatment at Whittington Health at the end of January 2018.

The total number of patients waiting longer than 18 weeks for treatment (backlog) at the end of January 2018 was 1,202. This number has remained consistently around the 1,200 mark since September 2017.

Whittington Health incorrectly reported their January 2018 diagnostic waiting time position as non-compliant with the 99% seen within six week standard. This was due to an error on the part of Whittington Health. Actual performance was that Whittington Health was compliant and 99.1% of patients were seen within six weeks for their test.

For all diagnostic test categories 92% or more patients were tested within six weeks.

Whittington Health has confirmed they have reviewed their reporting validation processes to prevent further errors occurring when uploading data to national reporting systems in the future. Nationally reported data will continue to be incorrect until NHS Digital refresh their reports for quarter four 2017/2018.

Waiting times for colonoscopy, gastroscopy and flexi-sigmoidoscopy have been affected due to a vacant endoscopy nurse specialist post which has now been appointed to. Whittington Health had predicted these specialties would be compliant with the 99% within six week standard by January 2018 but this has been delayed until March 2018 as booking schedules and templates are reconfigured.

Whittington Health has a record of sustained achievement of the 92% 18 week referral to treatment and six week diagnostic waiting time standards.

At this stage no further action is recommended other than continued monitoring of Referral to Treatment Time and Diagnostic Performance at Contract Monitoring Group and Clinical Quality Review Group.

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Referral to Treatment Time and

Diagnostics

Backlog of Radiology Test Reporting

In March 2018 Whittington Health reported that as part of a review exercise they had identified approximately 3000 radiology scans that had not been reported, some of which dated back to 2014.

There is a project group that is reviewing the images weekly basis, and a weekly update is share with the Radiation Safety Committee. To date there have been no significant clinical findings or concerns raised by clinicians. The work to address the backlog is due to be completed by the end of April.

Whittington Health have not declared this as a Serious Incident but have reviewed all Serious Incidents over the last year and themes from previous years and have found no connection between the reporting delays and serious incidents.

Backlog of Radiology Test ReportingProject group set up and meeting weekly to review progress in reducing the backlog and ongoing clinical risk.

Membership includes Consultant radiologists, radiographers, radiology information technologyspecialists and senior management.

Whittington Health information team is generating weekly reports on backlog and supporting with system interrogation

Processes around auto reporting are being strengthened within Whittington Health.

Whittington Health are preparing a report on test to report waiting times which will be shared with Healthwatch Haringey and Haringey and Islington Quality Committees.

Backlog of Radiology Test Reporting

Update on review process due at both Clinical Quality Review Group and Contract Review Group in April 2018.

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CQUINs (Commissioning for Quality and Innovation)

CQUIN Quarter 3 2017/2018 Status Comments Infections (AMR and Sepsis) AchievedNational 4: Improving Services for People with Mental Health Needs Who Present to ED Achieved

National 6: Offering Advice and Guidance Achieved

• Data submitted via SDCS portal. A&G covers over 35% of activity• Timetable and implementation aligned with STP - on track.

National 7: NHS e-Referrals Achieved

• 90% of Referrals to 1st O/P Services able to be received through e-RS• ASIs reduced to 10% in line with agreed trajectory

National 8: Supporting Proactive and Safe Discharge In progress

•As discussed with CCGs - Whittington Health Trust Management Group have approved to delay implementation until April 2018 to enable the testing, training and downtime of software implmentation to be managed in a realistic manner.

National 11: Personalised Care and Support Planning Achieved

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E Referrals

2018/2019 – NHS Standard Contract• By 1 October 2018 all NHS Providers need to use E Referral as their only means of making and receiving referrals from GPs to

consultant led first outpatient appointments• This can only be achieved through joint working between CCGs and providers and is being led by the North Central London E Referral

Implementation and Steering Group chaired by Denise Pettit from Haringey CCG.

0.0%

20.0%

40.0%

60.0%

Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

OP % Utilisation

WHITTINGTON HEALTH NHS TRUST

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Community Services

Two performance reports for Whittington Health Community services are included in this report. One replicates the 2016/2017 reporting format and the other is a ‘work in progress’ report in which Whittington Health breaks down waiting time by routine and urgent and average waits.

Within the 2016/2017 reporting format six of 31 services saw 95% of patients within six weeks and nine of 31 services saw 90% of patients within six weeks January 2018.

Against the District Nursing target of 80% of urgent patients being seen within two hours Whittington Health achieved 83% in February 2018. Against the target of seeing 95% of patients within 48 hours Whittington Health achieved 91% in February 2018.

PA Consulting have been appointed by the Haringey and Islington Wellbeing Board to undertake a defined piece of project work with regard to Whittington Health Community Services to conclude in May 2018.

The remit of the programme includes:• Review of current service provision• Format of performance reporting• Recommendations for future

strategy

A Task and Finish Group meets in April 2018 to consider future reporting arrangements and improvement trajectories and reports to the Community Services Improvement Group.

Each community service provides an annual report (or more frequently if required) to the Whittington Health Clinical Quality Review Group including GP representatives from Haringey and Islington CCGs and a patients’ representative.

The Community Service Improvement Group has been established, is chaired by the Chief Operating Officer for Whittington Health NHS Trust and Director of Haringey and Islington Wellbeing Board and includes GP and community service clinical representation.

The Wellbeing Board will make regular reports to the relevant Haringey and Islington Quality and Performance Committees going forward regarding the work of the Community Service Improvement Group and the project work undertaken by PA Consulting.

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Whittington Health NHS TrustQuality Summary

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Current Position/Risks Mitigating Actions Recommendations

Cancer Quality Update

Whittington Health was compliant for all cancer standards apart from 62 day which was 82.2% against a standard of 85%. Whittington Health was compliant for two week waits for January 2018. Colorectal and Upper Gastro-enterology did not meet the standard of 92% although the Trust was compliant overall. Colorectal and Upper Gastro-enterologyoperate a straight to test pathway. There is a plan in place where capacity has been identified in endoscopy so that there is sufficient capacity for these patients. This is demonstrating an improvement in March 2018.

• During 2017/18 NCL & NEL have been working to ensure that all inter trust tertiary referrals are sent from the original hospital by 38. The Trust has had a varied performance against this standard, which has been identified as a key indicator to delivery of 62 day standard. Work continues to improve this performance which is usually related to:

• Urology: issues with prostate patients being referred promptly to UCLH

• Gynaecology have been affected by one late referral, numbers are small

• Upper and Lower Gastro-enterolgoy: currently related to the delays in getting endoscopy procedures completed.

This standard is being monitored closely across NEL and NCL.

Quarterly Updates to Clinical Quality Review Group .

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Area Current Position/Risks Mitigating Actions Recommendations

PressureUlcers

Comparing the avoidable pressure ulcers across the Trust between April – January 2016/17 with the same period 2017/18

• An increase in category 2 pressure ulcer by 12.8% (6),

• An increase in category 3 pressure ulcer by 17% (4)

• No increase in category 4’s

Comparing the number of avoidable pressure ulcers within district nursing during the same period has seen:

• A 25% increase in Category 2’s (7)

• A 22.3% increase in category 3’s (4)

• No increase in avoidable Category 4’s.

(Tissue Viability Nurse Report to CQRG March 2018)

All pressure ulcers category 2 – 4, ungradable are reported as clinical incidents using the Datix system. Any Category 3, 4 or ungradable attributed to Whittington health is investigated using the pressure ulcer investigation tool.

Key Themes from investigations:• Shortfall in the assessment of patients (this includes skin

assessment, Waterlow assessment), which can be attributed to the nursing skill mix, and changes to the skill mix.

• There have been an increase in the Band 4. The Trust have relooked at how the assessment are undertaken, and who can complete these, and the rollout of bespoke assessment training.

• The documentation is also being reviewed, with a plan to streamline the document.

• In district nursing that has been an increase in the caseload and number of patient contacts, highlighting the need for a review of the skill mix, as every patient on the caseload requires a skin bundle.

• There is a planned programme of training that will be rollout to all grades of staff to be competent to undertake these tasks.

• Quality Rounds, which includes spot check of the notes and a review of patient by the Tissue Viability service, has been introduced on one ward with a plan for this to be rollout.

• A regular Audit of Care Notes has also been launched.

Update to Clinical Quality Review Group on implementation and outcomes of changes implemented June 2018

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23


Care Quality Committee Inspections

Following an inspection of four of the Trust services in November 2018, the Trust has retained its overall rating of Good, from the previous inspection.

The Trust were rated Outstanding in the Caring domain and Good in the Well Led domain, with both the Hospital and Community services rated as Good.

There are four regulated activity actions from the CQC report including: • Flow in ITU and delayed discharges• Ligature risk in CAMHS

The Trust provided a written response to the CQC in March 2018. The Trust reported that the actions have either been completed or will be completed within the next 3 months.

Clinical Quality Review Group informed and will monitor progress of the improvement plan .

Workforce • Mandatory Training achievement is at 81% against a target of 90%

• Data on 9th February show 2.8% sickness rate and data on 19th February show 3.48% sickness rate.( February 2018 Trust Integrated Performance Report)

• Vacancy Rate against establishment 12.5% February 2018, the increase in vacancy factor is at least partially attributable to temporary increases in establishment in December to deal with winter pressures. (Trust Integrated Performance Report February 2018)

• Appraisals and statutory and mandatory training remains of concern that, despite modest improvements in both these indicators in this month, they remain below target; it is expected that reinforcing their priority in recent quarterly reviews will provide a renewed focus to improving ICSU performance.

• December sickness rate is 3.48% which is slightly above target. An issue in delayed recording of sickness has been identified which show a significant discrepancy.

• After a successful assessment centre for newly, qualified nurses the Trust have recruited over 50 nurses, who are due to start in September 2018.

Clinical Quality Review Group informed and will monitor progress.

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Moorfields Eye Hospital NHS Foundation TrustProvider Key Messages

24

Key MessagesAccident and Emergency

Moorfields Eye Hospital performance against the four hour waiting time standard for February 2018 was 99.3% and there were nobreaches of the 12 hour decision to admit to admission standard.

Referral to Treatment Waiting Time and Diagnostic Waiting Times

Moorfields Eye Hospital performance against the incomplete 18 week referral to treatment standard was 94.02% for January 2018. No patients at Moorfields Eye Hospital were waiting over 52 weeks for treatment at the end of December 2017 and no patients waited longer than six weeks for a diagnostic test. While the 18 week incomplete position remains good there has been an increase in the number of patients waiting more than 18 weeks for treatment from 601 patients to 1618 patients from March 2017 to January 2018 . Moorfields Eye Hospital has provided the following statement:

‘There are separate plans for the north, south and city road (and for their individual specialities), that are focusing around demand and capacity and long term solutions to improve our RTT performance rather than quick reductions in our breaching patients. The divisions are looking at job plans, clinic structures, theatre utilisation, booking practices and clinical engagement, as well as more service specific endeavours, to improve our RTT position percentage back to previous levels.’

To further understand the above plans and agree trajectories for performance a meeting has been convened for April 2018 with representatives from South West London commissioners and Islington CCG as lead commissioner.

Cancer

In January 2018 Moorfields Eye Hospital achieved all relevant national cancer access standards.

Moorfields Eye Hospital monitors the percentage of patients seen within two weeks of referral to the NHS England commissionedspecialist service. In February 2018 86.1% of the 72 patients referred to the Ocular Oncology Service were seen within two weeks of referral. Of the ten patients not seen within two weeks eight were delayed due to patient choice or clinical reasons. These patients are not necessarily being referred for first treatment or diagnosis which can make co-ordinating appointments and persuading patients of the urgency of their case less straightforward than for traditional GP referred suspected cancer referrals. 71 of 186

Moorfields Eye Hospital NHS Foundation TrustProvider Key Messages

25

Key MessagesE Referrals2017/2018 CQUIN• Ensure that 100% of GP Referrals to 1st Outpatient Services can be made through E Referral by March 2018• Appointment Slot Issues (this is when a GP refers using E Referral but an appointment is not available electronically at the receiving

provider) no more than 4% of completed referrals by March 20182018/2019 – NHS Standard Contract• By 1 October 2018 all NHS Providers need to use E Referral as their only means of making and receiving referrals from GPs to

consultant led first outpatient appointments.• This can only be achieved through joint working between CCGs and providers and is being led by the North Central London E Referral

Implementation and Steering Group chaired by Denise Pettit from Haringey CCG.

0.0%

50.0%

100.0%


OP % Utilisation

MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST

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Moorfields Eye Hospital NHS Foundation TrustPerformance Dashboard

Elective Care (RTT, Diagnostics & CWT)Non Elective (A&E)

26

18 Weeks RTT Admitted - 80.76% 83.41%




>52 week waits Non Admitted - 1 7

>52 week waits Incomplete 0 0 5

6 Weeks Diagnostic Waits 1% 0.00% 0.00%

Cancelled Operations (2017-18 Q3) 100% 96.20% 97.47%

2 Week Cancer Wait 93% 100.0% 97.8%

31 day Cancer Wait:1st definitive treatment 96% 100.0% 93.1%

31 Day Cancer Wait: Subsequent treatment (Radiotherapy) 94% 100.0%

31 Day Cancer Wait: Subsequent treatment (Surgery) 94% 100.0% 100.0%

62 Day Cancer Wait: GP Referral 85% 100.0%

62 Day Cancer Wait: Consultant Upgrade

KPI/ThresholdMoorfields Eye Hospital

Jan-18 YTD


Jan-18 YTD

A&E All Types Performance 95% 99.30% 98.54%

No of waits from decision to admit to admission (Trolly waits - over 12 hours)

0 0 0

% Ambulance Handovers within 15 mins: KPI 1 100% n/a n/a

% Ambulance Handovers within 30 mins: KPI 2 100% n/a n/a

Number of Ambulance Handover - 30 minute breaches 0 n/a n/a

Number of Ambulance Handover - 60 minute breaches 0 n/a n/a

% Patient Records Captured Electronically: KPI 4 90% n/a n/a


Feb-18 YTD


Feb-18 YTD

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27

Moorfields Eye Hospital NHS Foundation TrustQuality Dashboard





Number of MRSA Bacteraemia Jan-18 0 0


Mandatory Training rate Jan-18 89%

Average fill rate - Registered nurses/midwives (Day) Dec-17 98%

Average fill rate - Registered nurses/midwives (Night) Dec-17 103%

Average fill rate - Care staff (Day) Dec-17 85%

Average fill rate - Care staff (Night) Dec-17 106%

Patient Safety

2 20 0 0

3

0

3 2

21

99% 80% 103% 95% 90% 92% 95% 105% 100%

101% 97% 108% 98% 102% 104% 110% 109% 108%

90% 72% 83% 87% 98% 88% 103% 96% 94%

97% 83% 119% 100% 123% 110% 103% 113% 117%

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28

Moorfields Eye Hospital NHS Foundation TrustQuality Dashboard



VTE - % patients who have had a VTE assessment within 24 hours of admission Dec-17 98.6% 98.7%

Cancelled operations - Number of patients not treated within 28 days of last minute elective cancellation 2017-18 Q3 3 10

Friends & Family test (FFT) - % Recommend Inpatients Jan-18 98.8%

Friends & Family test (FFT) - Response Rate % Inpatients Jan-18 55.7%

Friends & Family test (FFT) - % Recommend A&E Jan-18 95.3%

Friends & Family test (FFT) - Response Rate % A&E Jan-18 13.0%

Friends & Family test (FFT) - % Recommended Outpatients Jan-18 97.3%

Friends & Family test (FFT) - Response Rate % Outpatients Jan-18 15.0%





Mixed sex Accommodation - Breaches Feb-18 0 0

Complaints - Number of formal complaints (Trust data) 2017-18 Q2 52 112


Patient Experience

21

4 3 3

100% 99% 99% 99% 99% 99% 99% 99% 99%

59% 53% 57% 61% 58% 55% 51% 50% 56%

12%17%

11% 14% 16% 16% 18%07% 13%

69% 65%78% 70% 67%

99% 99% 98% 99% 99% 98% 99% 99% 99%

2% 2% 3% 1% 3%

16% 17% 10% 13% 16%

94% 95% 95% 96% 95%

95% 95% 95% 95% 96% 93% 92%97% 95%

96% 97% 96% 97% 96% 96% 97% 97% 97%

12% 13% 12% 15% 14% 13% 10% 10%15%

57 35 46 65 60 5275 of 186

Moorfields Eye Hospital NHS Foundation TrustQuality Summary

29


Duty of Candour

Moorfields Eye Hospital needs to submit evidence of compliance with stage two for 2016/17.

An audit of the Duty of Candour and Being Open process is to be carried out, to assure that the process is being followed through to completion.

This retrospective review will seek to confirm that the process was followed appropriately and families were contacted directly, particularly where no written record exists for stage two

The request was made at March 2017 Clinical Quality Review Group to submit required evidence for the previous year and how Moorfields has improved recording and implementation going forward.

Update at July 2017 Clinical Quality Review Group was that Moorfields Eye Hospital is on track with compiling evidence of actions around Part Two despite logistic issues in obtaining evidence from patients and their families.

Evidence to be submitted March 2018 Clinical Quality Review Group .

Current status of audit progress discussed with Contracts team at NEL Commissioning Support Unit has contract implications.

Moorfields Eye Hospital to report back to the Clinical Quality Review Group and via operational report once changes have been made and audit completed in March 2018.

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30


Workforce The rolling annual turnover rate is currently 17.4%, which is notably lower than it was a year ago. Stability remains well above our target minimum of 80%. Turnover hot spotsinclude Clinical Support and Administrative staff.

The vacancy rate is currently 13.4%. Hot spots include parts of Moorfields South and Theatres at City Road.

The Appraisal rate and Statutory/Mandatory Training rate are both above our target threshold rates, at 84% and 88% respectively.

73% of staff would recommend Moorfields as a place to work, and 92% would recommend Moorfields as a provider of care.

Source: Moorfields Eye Hospital quarterly workforce report March 2018

Key Workforce Metrics: The rolling annual sickness rate has remained at 4.0% over the past quarter. However, a key contributing factor is the improved reporting and recording of sickness as e-rostering is being rolled out to more units across the trust. Sickness absence staff group hot spots include Clinical Support and Registered Nursing staff.

Stress, Anxiety & Depression accounted for the most calendar days lost due to sickness over the past quarter, as well as the most episodes of long-term sickness.

Clinical Quality Review Group to monitor monthly and quarterly.

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Area Mitigating Actions Recommendations

Care Quality Commission

Update

Care Quality Improvement Plan Update

Moorfields Eye Hospital commissioned an internal audit review to test themselves on the implementation of the improvement plan; the initial feedback has been positive.

• The CQC improvement plan contained 78 recommendations in 50 actions. The Trust have made good progress with implementing the actions, and have completed 82% (41 actions).

• St Georges Hospital refurbishment is on track and with completion in 6-8 months.

• Duty of Candour in-house e-learning module is being developed with a filming date in April 2018.

• Children and Young Persons Strategy, has been developed and is in the consultation stage.

• A number of the Service Level Agreements have been signed off; however Mile End, Northwick Park, and St Georges remain outstanding. The Trust reported that for St Georges the principles are in place the financial agreement remains outstanding.

Clinical Quality Review Group to monitor monthly and quarterly.

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NHS Digital data published by NHS DigitalLocal data derived from Provider reports to NHSE

32

Islington CCGImproving Access to Psychological Therapies

Performance Dashboard

Theme KPI/Measure Source Reporting Period Actual Standard Current Month and Previous Month's Trend


% Waited less than 6 weeks for a course of treatment (for those finishing a course of treatment)

NHS Digital Dec-17 88.00% 75%



Reliable Recovery Rate NHS Digital Dec-17 43.00%

Recovery Rate NHS Digital Dec-17 47.00% 50%

Recovery Rate - QUARTERLY NHS Digital 2017-18 Q3 47.00% 50.00%

Access Rate NHS Digital Dec-17 1.36% 1.40%

Access Rate - QUARTERLY NHS Digital 2017-18 Q3 4.23% 4.20%

BME % of Numbers Entering Treatment - QUARTERLY NHS Digital 2017-18 Q3 45.32%

ISLINGTON CCG IAPT

80.00%86.00% 81.00%

88.00% 88.00% 85.00% 87.00% 86.00% 84.00% 83.00% 84.00% 87.00% 88.00%

Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

100.00% 97.00% 99.00% 99.00% 97.00% 99.00% 97.00% 97.00% 98.00% 98.00% 98.00% 98.00% 98.00%


42.00% 38.00% 40.00% 52.00% 55.00% 44.00% 49.00% 41.00% 46.00% 43.00% 42.00% 44.00% 43.00%


47.00% 43.00% 44.00% 54.00% 58.00% 45.00% 53.00% 47.00% 49.00% 46.00% 46.00% 48.00% 47.00%


1.29%1.63% 1.45% 1.42% 1.54%

1.38% 1.41% 1.32%1.14% 1.22%

1.63%1.36%


46.67% 47.00%52.00%

48.00% 47.00%

2016-17 Q3 2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

3.92% 4.50% 3.92% 3.87% 4.23%

2016-17 Q3 2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

47.74% 52.33% 48.18% 45.90% 45.32%

2016-17 Q3 2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

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33

Islington CCGMental Health Performance Dashboard

*Latest data is provisional and unpublishedNHS Digital data published by NHS DigitalLocal data derived from Provider reports to NHSE



Dementia Diagnosis Rate (Age 65+) NHS Digital Feb-18 91.16% 66.7%

The percentage of RTT First Episode Psychosis (FEP) periods within 2 weeks of referral. *

NHS Digital Feb-18 77.78% 50%

Proportion of patients on CPA who were followed up within 7 days after discharge from psychiatric inpatient care

NHS Digital 2017-18 Q3 96.30% 95%

Proportion of admissions to acute wards that were gate kept by the CRHT teams

NHS Digital 2017-18 Q3 99.13% 95%

Proportion of Children and Young people with eating disorders (routine cases) that wait 4 weeks or less from referral to start of NICE-approved treatment

NHS Digital 2017-18 Q3 87.50% 95%

Proportion of Children and Young people with eating disorders (urgent cases) that wait 1 week or less from referral to start of NICE-approved treatment

NHS Digital 2017-18 Q3 100.00% 95%

ISLINGTON CCG

MENTAL HEALTH

96.41% 96.83% 92.70% 92.66% 92.06% 92.47% 92.04% 91.96% 91.32% 92.03% 92.17% 91.65% 91.16%


80.00% 77.78% 80.00% 80.00% 100.00% 77.78%50.00%

88.89% 100.00%66.67% 90.00%

58.33% 77.78%


97.67% 98.63%

94.59%96.30%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

100.00% 99.21% 99.14% 99.13%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

81.25%88.00% 87.50%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

100.00% 100.00% 100.00%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

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34

Camden CCGImproving Access to Psychological Therapies

Performance Dashboard








Recovery Rate NHS Digital Dec-17 40.00% 50%

Recovery Rate - QUARTERLY NHS Digital 2017-18 Q3 44.00% 50.00%

Access Rate NHS Digital Dec-17 0.91% 1.40%

Access Rate - QUARTERLY NHS Digital 2017-18 Q3 3.54% 4.20%


CAMDEN CCG IAPT

82.00% 83.00% 83.00% 86.00% 88.00% 89.00% 86.00% 87.00% 89.00% 89.00% 88.00% 84.00% 85.00%


98.00% 98.00% 97.00% 99.00% 98.00% 99.00% 99.00% 99.00% 100.00% 99.00% 99.00% 98.00% 97.00%


45.00% 43.00% 48.00% 45.00% 42.00% 40.00% 44.00% 46.00% 53.00% 45.00% 46.00% 40.00% 35.00%


48.00% 46.00% 51.00% 47.00% 47.00% 45.00% 49.00% 52.00% 54.00% 51.00% 48.00% 42.00% 40.00%


1.30%1.77% 1.49% 1.74% 1.46% 1.80% 1.61% 1.50%

1.27% 1.18% 1.27% 1.36%


44.00%48.00% 47.00%

52.00%44.00%

2016-17 Q3 2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

4.42% 5.00% 4.86% 3.96% 3.54%

2016-17 Q3 2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

48.46% 46.32% 51.39% 52.56% 50.76%

2016-17 Q3 2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

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35

Camden CCGMental Health Performance Dashboard




Dementia Diagnosis Rate (Age 65+) NHS Digital Feb-18 88.49% 66.7%




NHS Digital 2017-18 Q3 92.41% 95%


NHS Digital 2017-18 Q3 98.64% 95%

Proportion of Children and Young people with eating disorders (routine cases) that wait 4 weeks or less from referral to start of NICE-approved treatment

NHS Digital 2017-18 Q3 86.96% 95%

Proportion of Children and Young people with eating disorders (urgent cases) that wait 1 week or less from referral to start of NICE-approved treatment

NHS Digital 2017-18 Q3 100.00% 95%

CAMDEN CCG

MENTAL HEALTH

74.79% 75.37%86.65% 86.41% 87.55% 87.22% 87.56% 88.04% 88.96% 88.51% 88.06% 88.38% 88.49%


91.67% 100.00%70.00% 85.71% 100.00% 83.33% 80.00% 92.86% 100.00% 75.00% 75.00% 100.00% 81.82%


95.71% 98.41% 93.83% 92.41%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

99.30% 98.50% 99.26% 98.64%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

66.67% 75.00% 88.46% 86.96%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

100.00% 100.00% 100.00% 100.00%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

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36

Islington ICope Improving Access to Psychological Therapies

Provider Performance DashboardTheme KPI/Measure Source Reporting

Period Actual Standard Current Month and Previous Month's Trend Blue = NHS Digital Green = Local Data Red = Target

NHS Digital Dec-17 85.71%

Local Data Feb-18 84.58%






NHS Digital 2017-18 Q3 47.00%

Local Data 2017-18 Q3 47.12%

NHS Digital Dec-17 420

Local Data Feb-18 440

NHS Digital 2017-18 Q3 1335

Local Data 2017-18 Q3 1312


ISLINGTON ICOPE IAPT


75%


95%

Recovery Rate 50.00%

Recovery Rate - QUARTERLY 50.00%

Numbers entering into Treatment 434

Numbers entering into Treatment - Quarterly

80.00%

88.00% 89.00%85.00% 87.00% 86.00% 84.00% 83.00% 84.00% 87.00% 85.71%

84.02% 89.00% 87.79% 86.92% 88.28% 86.96% 83.26% 84.09% 84.90% 87.79% 89.08% 90.00% 84.58%


99.00% 99.00%

97.00%

99.00%

97.00% 97.00%98.00%

99.00%98.00% 98.00%

97.14%

100.00%98.70%

97.09%

99.58%98.33% 98.70% 98.64% 99.09% 98.96% 99.06%

98.28%100.00% 99.00%


40.00%52.00% 56.00%

44.00% 49.00%40.00% 46.00% 43.00% 42.00% 44.00% 43.00%


44.00%

54.00%60.00%

45.00%

53.00%47.00% 49.00%

46.00% 46.00% 48.00% 47.00%

46.20%

55.00% 60.81%

46.41%

53.59%47.55% 50.00% 47.37% 46.43% 46.99% 48.03%

52.44%47.43%


445 440

315

485435 445 415

360 385

520

420

447 442

317

480435 442 411

336388

515

409

533440


48.00%52.00%

48.00% 47.00%

49.17%52.83%

48.29% 47.12%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

1385

1230 1220

13351388

12321189

1312

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

51.99% 47.97% 46.31% 45.32%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

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Camden ICope Improving Access to Psychological Therapies

Provider Performance DashboardTheme KPI/Measure Source Reporting

Period Actual Standard Current Month and Previous Month's Trend Blue = NHS Digital Green = Local Data Red = Target








NHS Digital 2017-18 Q3 44.00%

Local Data 2017-18 Q3 45.07%

NHS Digital Dec-17 340

Local Data Feb-18 489

NHS Digital 2017-18 Q3 1315

Local Data 2017-18 Q3 1274


CAMDEN ICOPE IAPT


75%


95%

Recovery Rate 50.00%

Recovery Rate - QUARTERLY 50.00%

Numbers entering into Treatment 513

Numbers entering into Treatment - Quarterly

81.00%84.00% 83.00%

88.00%85.00% 86.00%

89.00% 89.00% 88.00%84.00% 85.00%

82.57%86.30% 84.07%

89.21%84.64%

87.83% 88.05% 89.46% 86.90% 86.81% 87.37% 85.32%82.79%


96.00%

99.00%

97.00%

99.00% 99.00% 99.00%100.00%

99.00% 99.00%98.00%

97.00%

97.25%98.40% 98.35%

99.17% 99.06% 99.24% 99.66% 98.98% 98.41%99.57%

97.98%99.21%

96.31%


46.00% 43.00% 40.00% 40.00% 44.00% 47.00% 53.00% 46.00% 45.00% 39.00% 34.00%Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

50.00%45.00% 44.00% 45.00%

50.00% 52.00%55.00%

51.00%48.00%

42.00% 40.00%

50.80% 49.50% 50.00%46.43%

51.64% 52.70% 55.27% 51.48% 50.00%

42.79% 41.10%

49.52%46.98%


510580

490

675595 555

470 435 470 505

340

487577

465

654 578 547465

424 461 494

319

527 489


47.00% 47.00%53.00%

44.00%

52.68%49.59%

53.16%

45.07%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

1690 1760

14651315

1657 1697

1436

1274

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

46.15% 51.14% 52.56% 50.57%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

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38

Camden & Islington Foundation TrustMental Health Performance Dashboard

Theme Source Reporting Period Actual Standard Current Month and Previous Month's Trend

Blue = NHS Digital Green = Local Data Red = Target


NHS Digital 2017-18 Q3 95.45% 95%

NHS Digital 2017-18 Q3 99.16% 95%

% Assessments begun within 1 hour in A&E Local Data Sep-17 88.62% 95%

% Assessments begun within 4 hours in AMU Local Data Sep-17 98.80% 95%

% Assessments begun within 24 hours on wards Local Data Sep-17 82.14% 95%




% Assessments begun within 4 hours in AMU Local Data Sep-17 100.00% 95%


KPI/Measure

C&I MENTAL HEALTH TRUST




Whittington

UC

LHR

oyal Free

86.36% 90.48% 72.22% 84.21% 93.75% 80.00% 75.00% 90.00% 100.00%70.00% 78.95% 72.22% 78.95%


96.30% 98.41% 95.52% 95.45%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

100.00% 99.59% 99.12% 99.16%

2016-17 Q4 2017-18 Q1 2017-18 Q2 2017-18 Q3

92.2% 90.8% 82.4% 79.6% 85.1% 87.6%76.5%

88.6%


99.2% 97.9% 100.0% 100.0% 100.0% 98.1% 97.6% 98.8%


90.38% 95.65% 84.21% 83.33% 82.86% 82.35%70.73%

82.14%


95.6% 93.0% 92.7% 88.9% 91.5% 90.7% 85.9% 86.2%


84.09%90.00% 86.05% 91.18% 90.91% 89.19% 90.24% 90.00%


90.8% 85.5% 91% 86% 85% 83% 88% 92%


100.0% 100.0% 99% 98% 98% 99% 100% 100%


91.84% 96.36% 93.33% 96.08% 92.73% 94.74% 94.00% 96.23%


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Key Messages

Improving Access to Psychological Therapies

• Access Rates – Local data from Camden and Islington NHS Foundation Trust Improving Access to Psychological Therapies services shows that the number of patients entering treatment was:

• 440 for Islington against a target of 434 (101%)• 489 for Camden against a target of 513 (98.9%)

• Waiting Times – Camden and Islington NHS Foundation Trust report that the percentage of patients accessing treatment within 6 weeks and within 18 weeks was over the agreed standards of 75% and 99% respectively for Camden and Islington CCGs in February 2018.

• Recovery Rates – Camden and Islington NHS Foundation Trust reported recovery rate data for February 2018 shows a recovery rate of 46.98% for Camden CCG and 47.43% for Islington CCG. The general downward trend in recovery rates for both CCGs that was seenprior to December 2017 has been reversed and for both CCGs Camden and Islington NHS Foundation Trust has assured it is on track to deliver its commitment of 50% recovery rate by Quarter Four 2017/2018.

• Other Performance Indicators - National Standards for treatment times for First Episode of Psychosis (FEP), follow up within seven days of discharge for Care Programme Approach patients and gatekeeping of acute admissions by Crisis Resolution Home Treatment teams were all met by Camden and Islington NHS Foundation Trust for the last relevant reporting period.

Mental Health patients presenting to Accident and Emergency Departments

A Recovery Suite for patients with mental health problems has been built at Whittington Health and is ready to open. Camden and Islington NHS Foundation Trust reported at the March 29 2018 Islington A&E Delivery Board that it did not expect to be in a position to open the unit until the end of April 2018 as staff were not in post for the unit. The Board asked Camden and Islington NHS Foundation Trust to expedite the opening of the unit if at all possible.

Data for September 2017 shows that not all timescales for providing emergency liaison support to Emergency Departments (within one hour) and to inpatient wards (within 24 hours) were being met across the acute providers (University College London Hospitals, Royal Free London NHS Foundation Trust Hospitals and Whittington Health NHS). The contracts for this performance are held by the acute providers with Camden and Islington NHS Foundation Trust directly but the CCG and NEL CSU are supporting acute providers in their management ofthese contracts.

Camden & Islington NHS Foundation TrustProvider Key Messages

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Camden & Islington NHS Foundation TrustQuality Dashboard





Proportion of Patients New Pressure Ulcers(Safety Thermometer) Feb-18 0 1

Proportion of Patients Falls With Severe Harm (as per NPSA definition - Safety Thermometer) Feb-18 0 3

Mandatory Training rate 2017-18 Q1 76%

Average fill rate - Registered nurses/midwives (Day) Dec-17 99%

Average fill rate - Registered nurses/midwives (Night) Dec-17 99%

Average fill rate - Care staff (Day) Dec-17 99%

Average fill rate - Care staff (Night) Dec-17 123%

Friends & Family test (FFT) - % Recommend - Mental Health Jan-18 93.8%

Friends & Family test (FFT) - Response Rate % Mental Health Jan-18 10.1%





Complaints - Number of formal complaints (Trust data) 2017-18 Q3 28 96

Patient safety

Patient experience

5 52

6

0 15 7 4

9.60% 12.85% 13.71% 13.07% 13.33% 9.50% 7.83% 10.08%

90% 89% 93% 90% 89% 91% 88% 94%

98% 97% 96% 96% 94% 94%100% 98% 99%

97% 98% 97% 96% 97% 95% 98% 100% 99%

116% 108% 110% 109% 109% 106% 98% 99% 99%

131% 115% 114% 119% 123% 116% 119% 123% 123%

21

0 0 0 0 0 0

28 26 35 33 28

83.10% 78.60% 77% 77% 80% 76%

68% 68% 67% 61% 51%

20% 20% 20% 23% 28%

71% 71%60% 64% 62%

12% 12% 19% 13% 15%

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Camden & Islington NHS Foundation TrustQuality Summary

41

Area Key Issues Key Actions Recommendations

Care Quality Commission

Improvement plan

The Care Quality Commission (CQC) undertook their formal inspection in December 2017. Camden & Islington NHS Foundation Trust has been rated good which is an improvement on its previous rating of requires improvement. The final report was published 6th March 2018 and the organisation held a quality summit with its key partners on 8th March 2018 to identify its success and future developments required to achieve an outstanding rating at any future inspection.

.

Camden & Islington NHS Foundation Trust was given 7 Must Do Actions and 56’ should Do Actions.’ The 7 Must Do actions are attached to this report. The ‘should do’ action plan is currently being drafted.Key points:

• Completion of mandatory training

• Sufficient staffing to cover shifts

• Comprehensive records keeping after restraint and rapid tranquilisation

• Appropriate care models to support and promote independent living and access to community services

• Sufficient Occupational Therapy on inpatient rehabilitation wards

• High caseloads in Crisis Home Recovery Team

Clinical Quality Review Group continues to review and monitor progress.

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42


Serious Incidents Summary

There were 22 open serious incident investigations. (21 level 1s and 1 level 2).

There were 14 new serious incidents between 1 January and 28 February 2018. (7 in January and 7 in February).

There are 8 serious incidents still open from the previous reporting period

There were 10 incident investigations completed and reported during this period. The most common serious incident category remains unexpected death in the community.

(Serious Incidents and Complaints Report Summary for the period 1st

January – 28th February 2018 Camden & Islington NHS Foundation Trust )

Camden & Islington Foundation Trust have made great effort to submit the overdue reports, and the current number of overdue reports are much lower than previously.

Due to the ongoing delays in identifying Serious Incidents authors and investigators, and finalising the report for sending to the CSU means that the projection indicates ongoing delays. Camden & Islington NHS Foundation Trust are working to mitigate these.

Clinical Quality Review Group to continue to monitor.

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Complaints Complaints Summary

• 12 new formal complaints received in January 2018, 7 in February 2018

• The oldest complaint currently open was received in May 2017. This is a complex complaint involving the need to reassess the service user.

• 23 complaints were responded to during this period, 9 in January and 14 in February

• 12 complaints were not upheld, 6 were partially upheld and 3 fully upheld. 2 complaints were withdrawn.

(Serious Incidents and Complaints Report Summary for the period 1st

January – 28th February 2018 Camden & Islington NHS Foundation Trust)

Themes were:

• Communication with families and service users, including sharing information about decisions, continues to be raised frequently

• Discharge and assessment

• Waiting times for some services

• Staff attitudes

Camden & Islington NHS Foundation Trust has continued to experience challenges in regards to complaint investigations being completed on time; the current year to date compliance rate is 57% completed on time against a target of 80%. With the aim of addressing this, the complaints policy has recently been revised to ensure that there is flexibility in timescales for addressing more complex complaints or where delays occur due to factors outside investigators’ control. The team has also been meeting with divisional leads to discuss the pressure points and how to address these, and has begun

Clinical Quality Review Group to continue to monitor.


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Workforce • There were less staff leavers in Quarter Three 2017/2018 compared to Quarter Two shown by the reduced turnover rate at 4.8% in Quarter Three compared to 5.3% in Quarter Two; significant progress against Staff First programme in regards to internal promotions has contributed to this reduction. At the end of Quarter Three (1 April 2017 to 31 Dec 2017)

• The Budgeted Establishment Full Time Equivalent increased by 43.38 in Q3 – the rise was mainly in Acute Divisions.

• The increase in Full Time Equivalent mentioned above contributed to the vacancy rate rising from 12.0% in Q2 to 13.6% in Q3.

• Temporary Workforce spend rose in Q3 by circa £316K compared to Q2. The rise in sickness absence rate to 3.8% in Q3 from 3.5% in Q2 may have resulted in the rise in spend.

(Camden & Islington NHS Foundation Trust workforce Q3 Report April 2018)

• A new criteria for requesting agency staff has been developed and is operational across Camden & Islington NHS Foundation Trust.

• A new dashboard showing temporary staffing usage has been developed and is in place. The dashboard will further help to surface usage by Division and cost centre level and support discussions and actions accordingly

• Core Skills compliance across Camden & Islington NHS Foundation Trust increased to 76.3% in Q3 from 63.4% in Q2, ongoing effort continues to reach the Trust set target of 80%. As part of the CQC action plan, Core Skills compliance is a ‘must do action’ in 2018.

• Over the last four quarters Camden & Islington NHS Foundation Trust has seen a drop in the number of Black Minority Ethnic staff entering the formal stage of employment relationship process.

• Camden & Islington NHS Foundation Trust has recently increased scrutiny on temporary workforce spend and a new criteria for requesting agency staff is in operation. In addition the Finance Director and HR Director have been meeting with each Division to review agency spend.

Clinical Quality Review Group continues to monitor Serious Incidents monthly


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University College London Hospital -Performance Management Dashboard

.

18 Weeks RTT Admitted - 84.92% 85.05% A&E All Types Performance 95% 86.05% 88.24%




>52 week waits Non Admitted - 1 12 No of waits from decision to admit to admission (Trolley waits - over 12 hours)

0 1 3

>52 week waits Incomplete 0 3 24 % Ambulance Handovers within 15 mins: KPI 1 100% 35.60% 36.30%

6 Weeks Diagnostic Waits 1% 0.94% 0.75% % Ambulance Handovers within 30 mins: KPI 2 100% 83.40% 84.30%

Cancelled Operations (2017-18 Q3) 100% 91.35% 91.60% Number of Ambulance Handover - 30 minute breaches 0 201 2493


% Patient Records Captured Electronically: KPI 4 90% 91.80% 92.10%

2 Week Cancer Wait 93% 92.99% 94.35%

2 Week Cancer Wait:Breast Symptoms 93% 84.52% 92.70%

31 day Cancer Wait:1st definitive treatment 96% 90.44% 93.77%

31 Day Cancer Wait: Subsequent treatment (Surgery) 94% 90.12% 94.06% Category 1 Mean (min:sec) 0:07:00 0:07:26 0:07:16

31 Day Cancer Wait: Subsequent treatment (Chemotherapy)

98% 100.00% 100.00% Category 1 90th Centile (min:sec) 0:15:00 0:11:48 0:11:46

31 Day Cancer Wait: Subsequent treatment (Radiotherapy) 94% 97.50% 99.18% Category 2 Mean (min:sec) 0:18:00 0:23:21 0:21:36

62 Day Cancer Wait: GP Referral 85% 60.93% 68.14% Category 2 90th Centile (min:sec) 0:40:00 0:49:21 0:44:48

62 Day Cancer Wait: Screening service 90% 81.25% 75.47% Category 3 90th Centile (min:sec) 2:00:00 2:59:27 2:39:45

62 Day Cancer Wait: Consultant Upgrade - 69.81% 81.53% Category 4 90th Centile (min:sec) 3:00:00 2:34:17 2:33:31

Feb-18

KPI/ThresholdUNIVERSITY COLLEGE LONDON

HOSPITALS NHS FOUNDATION TRUST KPI/ThresholdUNIVERSITY COLLEGE LONDON HOSPITALS

NHS FOUNDATION TRUST

YTD

YTDKPI/Threshold

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

Jan-18 YTD Feb-18

KPI/ThresholdLONDON AMBULANCE SERVICE NHS TRUST

Feb-18 YTD

KPI/ThresholdUNIVERSITY COLLEGE LONDON

HOSPITALS NHS FOUNDATION TRUST

Jan-18 YTD

4892 of 186

University College London Hospital -Performance Management Summary

NEL CSU Performance Management Assessment

Subject

Description of performance management issue

Remedial actions undertaken NEL CSU recommendations

A&E(Accident & Emergency)

In February 2018 , University College London Hospital A&E performance was 86.1%, which is below the agreed trajectory of 91.0%, and below the 95% threshold. The projected March 2018 provisional A&E performance is 84.8%, and the projected 2017/18 provisional A&E performance is 87.9%.

There were breaches of the 12 hour trolley wait standard at University College London Hospital in October 2017, January 2018 and February 2018.

Camden CCG closed the 2016/17 A&E contract performance notice and issued a new 2017/18 contract performance notice on 12 April 2017. Performance remains at level 4 of the performance management framework. University College London Hospital has refreshed its Emergency Department recovery action plan and reprioritised the recovery actions which currently focuses on front door streaming, flow, better bed management and specialty and diagnostic improvements, and convening executive led daily meetings in January 2018.The recovery action plan and trajectories is discussed at A&E Delivery Board and at the Contract Review Group meetings.The University College London Hospital / Camden A&E system has:

• An internal exercise was conducted where all work packages on University College London Emergency Department Recovery and Improvement Plan have been reviewed and signed off at Emergency Care Recovery Board.

• This included updating the Red Amber and Green status of work packages, actions and timescales. The latest version was shared with Camden CCG on 13 February 2018.

• Continues to have bi-weekly escalation calls with NHS Improvement and NHS England.

• Opened the transition space in the emergency department to create 8/9 beds in January 2018.

• Convened executive led daily meetings since January 2018.

• University College London Hospital progresses with implementation of the revised A&E recovery actions derived from the jointly commissioned external review by McKinsey.

• Camden CCG continues to closely monitor University College London Hospital daily and weekly A&E performance via SIT REP reports and the weekly exception reports.

• Camden CCG monitors University College London Hospital A&E recovery action plan at the monthly Integrated Performance meetings.

• Camden CCG considers instigating a weekly conference call with University College London Hospital to discuss A&E under-performance and issues with flow. 49

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Subject

Description of performance

management issue


A&E(continued)

As part of the recovery plan there are a number of actions that have a critical impact on delivering the A&E trajectory:

• Increasing the number of patients on acute frailty ambulatory pathways

• Development and implementation of Discharge to Assess pathways

• The actions from the review of internal discharge processes and clinical utilisation that include rolling out a new clinical utilisation tool and implementing criteria-led discharge across medical wards.

The University College London Hospital / Camden system has successfully bid for winter money (£500,000) to:

• Enhance the RAPID service to support further admission avoidance and Discharge to Assess pathways 2 and 3

• Support an electronic coordination centre to maximise patient flow over a seven day period

• Enhance the staffing in a surge area in the Emergency Department.

University College London Hospital A&E Delivery Board to review the implementation and impact of the investment on A&E Performance.

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Subject



A&E(continued)

The Monthly Integrated Performance meetings with University College London Hospital were set up by Camden CCG / NEL Commissioning Support Unit in June 2016 where the A&E performance, Sustainability and Transformation Fund trajectories and above listed recovery action plans are reviewed. Since February 2018. this has become a joint Camden CCG/University College London Hospital meeting.

The A&E Delivery Board continues to monitor progress against the various work streams.

With the added focus on Delayed Transfers of Care by NHS England and NHS Improvement, Camden CCG and University College London Hospital continue to work closely on a daily basis to ensure numbers of Delayed Transfer Of Care and Medically Optimised are kept within acceptable limits.

A&E attendance analysis by practice has been requested by both University College London Hospital and Camden CCG and this constitutes to be one of the actions in the agreed Recovery Action Plan

Camden CCG supports University College London Hospital with the Discharge to Assess Sustainability and Transformation Plan work stream.

Camden CCG provides support for University College London Hospital in escalation of stroke repatriation issues and capacity issues with Mental Health beds.

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Subject



Ambulance Handover

London Ambulance Service handover overrides (activated when the Emergency Department has not received the PIN number regarding agreed handover time from London Ambulance Service) at University College London Hospital were 24.2% in February 2018, just below the whole of London figure of 25.4%.

University College London Hospital are continuing to carry out a successful initiative to improve handover times. In February 2018, handovers within the fifteen minute threshold maintained their consistency with a performance of 35..6%. This is a continuing improvement on the January 2017 figure of 27.1%. Similarly, handovers within the thirty minute threshold were 83.4% in January 2018 against the January 2017 figure of 72.7%.

A London Ambulance Service ambulance handover time improvement initiative is being undertaken as part of the University College London Hospital recovery action plan implementation.

In February 2018, London Ambulance Service to Emergency Department handovers, University College London Hospital challenged 25 out of 226 thirty minute handover breaches. Last month, in January 2018, University College London Hospital had challenged 50 out of 284 thirty minute handover breaches.

There were 61 sixty minute breaches in total in February 2018 of which six were challenged by University College London Hospital. Last month, in December 2017, University College London Hospital had 69 sixty minute breaches in total in January 2018 -of which 15 were challenged.

In December 2017 Camden CCG on behalf of the University College London Hospital A&E Delivery Board submitted a checklist to NHS Improvement. This is to support the recommended actions aimed to improve Ambulance Handover. The paper confirmed the recommended actions already taken and identified areas for further work.

NEL CSU recommends that Camden CCG works with University College London Hospital to ensure that senior representatives interface with London Ambulance Service, to discuss the current A&E pressures, review data andimplement action plans to minimise Ambulance Handover Breaches.

Continuation of London Ambulance Service action plan to recruit staff, and hence improve service performance.

Camden CCG/University College London Hospital A&E Delivery Board continues to develop, implement and review the impact of the recommended actions to improve ambulance handover. 52

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Subject



DiagnosticsUniversity College London Hospital again achieved the diagnostic target in January 2018 with a performance of 0.94%.

There were a total of 68 patients waiting over six weeks and seven patients waited over 13 weeks from a total waiting list size of 7, 228.

The non-compliant modalities this month were magnetic resonance imaging (1.4%), peripheral neurophys (1.7%), urodynamics (26.2%) and cystoscopy (3.7%).

The year to date diagnostics performance at University College London Hospital is currently achieving the target at 0.75%.

Camden CCG closed the 2016/17 diagnostics contract performance notice on the 31 March 2017 following University College London Hospital’s compliance against the standard for three successive months.

Actions include:

• Working group convened at Modality level• Business case being prepared for improvement

work in Peripheral Neurophysiology• Increase in capacity for Urodynamics is being

considered at University College London Hospital • 2017/18 Diagnostics Sustainability and

Transformation Fund trajectory indicates compliance across all months

• Zero tolerance allowed at modality level within University College London Hospital

• University College London Hospital completed the capacity and demand modelling for Magnetic Resonance Imaging, Computerised Tomography, Endoscopy and Non Obstetric US to better understand its demand and supply and engaged with the Transforming Cancer Services Team (TCST) who have led on this piece of work pan London.

• Endoscopy: University College London Hospital continues to deliver additional capacity, optimising in-house capacity and improving its booking processes.

NEL CSU recommends that:

Camden CCG continues to closely monitor University College London Hospital’s weekly and monthly diagnostics performance.

Camden CCG continues to review progress with the University College London Hospital diagnostics recovery action plans at the monthly Integrated performance meeting.


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Subject



Referral to Treatment

In January 2018, UCLH was non-compliant against the 18 Weeks RTT Incompletes Target for the seventh consecutive month with performance of 91.0% against the 92% Target.

This represents a small improvement in performance of (+0.3%) in performance when compared to December ’s performance of 90.7%. 37,939 patients were seen within 18 weeks from a total number of 41,671 incomplete pathways.

Three 52 week long waiters were reported for January 2018 and have been reviewed for any clinical harm and discussed at Clinical Quality Review Group.

University College London Hospital has developed specialty level recovery action plans and trajectories were signed off on 16 October 2017.

University College London Hospital continues to track backlog of affected specialties against a reduction trajectory.

Actions include:

Orthodontics: • Locum consultant started October 2017 • Brought forward current booked patients into new

capacity created by postgraduates started early in October 2017.

Paediatric dentistry:• New consultant started in October 2017• New specialty doctor fixed term started in September

2017• Replacement of lost post graduate appointments in

November 2017 was closed as no longer required.• Specialty on trajectory and continue to monitor

Restorative dentistry:• Review of waiting list management processes

commenced in October 2017• Postgraduates commenced in post in November

2017.• Deep dive meeting scheduled in December 2017

Camden CCG closely monitors University College Hospital London backlog clearing exercise for the challenged specialties at the monthly Integrated Performance meeting and Contract Review Group.

Camden CCG continues to review and monitor the Referral to Treatment patient tracking list snapshot received from University College London Hospital on a weekly basis.

Camden CCG ensures that the 52 week long waiters are reviewed for any evidence of clinical harm and discussed at the Clinical Quality Review Group meetings monthly.

Camden CCG requests additional information on the monthly report for patients waiting over 52 weeks to include assurance information requested by NHS England in relation to patient choice and offer for the alternate provider.


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SubjectDescription of performance management issue Remedial actions undertaken NEL CSU recommendations


The non-compliant specialties in January 2018 are as detailed below:

Ear Nose and Throat (83.9%) – 3,688 patients were seen within 18 weeks from a total of 4,395 incomplete pathways.

Neurosurgery (78.9%) – 637 patients were seen within 18 weeks from a total of 807 incomplete pathways.

Neurology (90.5%) – 1,961 patients were seen within 18 weeks from a total of 2,167 incomplete pathways

Other (90.9%) – 22, 373 patients were seen within 18 weeks from a total of 24,617 incomplete pathways

University College London Hospital submitted a refreshed Referral to Treatment recovery action plan and trajectories to Camden CCG on 15 December 2017 and this continues to be monitored at the integrated UCLH/CCG performance meetings monthly.

University College London Hospital had planned to return to overall compliance by January 2018 but this has been revised to March 2018.

Women's Health Gynaecology: - Inpatient Waiting list initiative approved for uro-gynaecology commenced in August 2017.- Additional weekend Out Patient clinics submitted to board - started September 2017.

Gastro intestinal Services:- Plan to increase clinician capacity, includes consultant, Inflammatory Bowel Disease (IBD) fellow, physiology fellow and physiologist. Posts come online between June and October 2017

Medical Specialties:Locum employed to back fill lists to free up consultants with the relevant skills.

Camden CCG requests additional information on the monthly UCL report for patients waiting over 52 weeks to include assurance information requested by NHS England in relation to patient choice and offer for the alternate provider.

Camden CCG keeps University College London Hospital on level 1 of the NEL CSU Performance Management Framework.

Backlog clearance continues and NEL CSU receives and reviews University College London Hospital’s Referral to Treatment (Referral to Treatment) recovery tracker and board pack on a weekly basis.


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Subject

Description of performance

management issue



Compliance for RTT forecast now for March 2018 - albeit recent indication received that community ENT service remains a significant risk to compliance.

Community Ear, Nose and Throat Services (ENT) - University College London Hospital• One additional clinic per week started beginning of December

2017• New Information Technology (IT) System introduced in October to

ensure that referrals will be listed in date order for booking team to book from

• Train new Royal National Throat, Nose and Ear validators

Allergy• Additional clinics through increase in utilisation of existing clinics

and utilisation of telephone clinics. • Service to hire an additional locum • Sustaining Patient Tracking List management improvements• NOTE: Allergy will not recover compliance at reporting unit level

within the life cycle of this plan. Full recovery is likely to be summer 2018.

If compliance is not attained in March 2018, recommend that Camden CCG applies formal contract levers.


As of 24 March 2018 University College London Hospital backlog position is as detailed below: Admitted backlog (922), Non-admitted backlog (3,562) and overall Incompletes backlog (4,484).

Queen Square:Neurology:New dementia clinic commenced September 2017 (complete)- Additional epilepsy activity expected - September clinics (complete), October clinics complete- Additional headache activity started October 2017.- Queens Square to provide timeline for additional 'super Saturday'

clinics. These have not been factored into the current version of the plan but would accelerate recovery from the new year.

Camden CCG keeps University College London Hospital on Level 1 of the NEL CSU Performance Management Framework


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Subject




Backlog clearance continues and NEL CSU receives and reviews University College London Hospital’s Referral to Treatment recovery tracker and board pack on a weekly basis.

Queen Square (continued):Neurosurgery:

Consultants have returned from leave. - Aiming to provide 80 additional clinics before the end of

March 2018. These clinics started in September 2017.

NOTE: Neurosurgery will not achieve compliance within life of this plan. This is due to disruption of theatre redevelopment likely to complete in April 2018.

Specialist Services:

- Autonomics - maternity leave cover in place. Expected impact from November 2017

- Neuropsychiatry - vacant Cognitive Behavioural Therapist post. Now recruited and starts October 2017

- Functional Neuropsychology Services (FNS) pathway: ensure clocks are appropriate stopped at outpatient appointment

- Uro-neurology: Ensuring clock stops appropriate documented in clinic letters

- Pain: Return of clinician. Improved DNAs through nurse led pre-assessment calls. Maternity leave cover in place

- Neuromuscular: additional Saturday clinic commenced in October 2017.

Camden CCG keeps University College London Hospital on Level 1 of the NEL CSU Performance Management Framework

Referral to treatment performance and issues continue to be discussed monthly at the integrated University College London Hospital/CCG Performance meeting and exceptions raised at CRG.


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Subject



Cancer WaitingTimes

University College London Hospital achieved three of the nine Cancer Waiting Times Standards in January 2018, which demonstrates a decline in cancer waiting time performance when compared to December 2017 performance. January 2018 performance decline was expected by University College London Hospital due to patient choice over December 2017 appointments, and a seasonal reduction in clinics at the Trust. In January 2018, the internal 62 Day Urgent GP referral Performance reduced to 68.2%, (from 88.1% last month) and University College London Hospital have attributed the drivers for non-compliance this month to: Patient choice, complex diagnostics, in the Urology Pathway. the two week wait median wait challenges remain in Children’s, Gynaecology, Lower GI, and Upper GI, and Sarcoma tumour groups.

A 2017/18 contract performance noticefor the Cancer 62 days Urgent GP referral was issued on 12 April 2017 as performance remains at level 4 of the performance management framework..

NHS Improvement have convened a bi-weekly steering group meeting with the University College London Hospital to discuss cancer performance and review trajectories.

A revised Cancer Recovery Action Plan and trajectories are expected to be agreed soon.

• Urgent implementation of signed off 2017/18 Cancer recovery action plans and implementation of the recommendations following the external clinical review by NHS Improvements Team in November 2017

• Attendance at University College London Hospital Patient Tracking list meetings

• Implementation of the 100+ Day Cancer Weekly review and sign off by Chief Executive

• University College London Hospital books all first out patient appointments by day seven across all tumour sites to reduce median waits

• Continuous review of e-referral appointments and achievement of the e-referral Commissioning for Quality and Innovation (CQUIN)

• Urgent work be carried out on the visibility of University College London Hospital cancer patient tracking list and Infoflex system

• Reinforcing Cancer escalation guidelines within University College London Hospital

• Improvement of the Urology tumour sites performance


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Subject



Cancer WaitingTimes

The underlying issues in January 2018:

For the 62 day treatment standard, there were 29.5 breaches, out of 76 total treatment pathways.

Tumour sites breakdown of breaches as follows:

• Breast (x2); Lung (x5.5); Haematology (x1.5); Upper GI (x1); Lower GI (x1.5); Gynaecology (x1.5); Urology (x11.5) Testicular (x0.5); Head and Neck (x4); Sarcomas (x0.5)

Breach reasons were as follows:

Patient Choice/Clinical Breaches:• 3.5 due to Patient Choice• 4.0 due to Patient Unfit• 1.5 due to Other Medical Condition Prioritised• 7.0 due to Exceptionally Complex Treatment

PathwayAdministrative/Capacity Breaches

• 0.5 due to Capacity• 4.0 due to Delay in work up• 2.0 due to Administrative issues• 7.0 due to Intertrust with no Information

Critical actions:

Increase breast imaging capacity and improve imaging pathway due 30 November 2017.

Improve head and neck Inter Trust Transfer (ITT) referral pathway, due 30 September 2017. This is now being picked up as part of the bilateral meetings across NCL.

Ensure all escalation actions are reported as completed at trust Patient Tracking List Meetings (PTL’s).

All 62 day+ breaches, including all those over 100 day breaches have breach analysis undertaken and is analysed and reported together at Clinical Quality Review Group.

• Reduction of urology and lower gastro intestinal Patient Tracking List backlogs

• Urgent review of the 38 day Inter Trust Transfer NCL trajectories from referring providers into University College London Hospital for 2017/18 and monitoring of 24 day treatments within University College London Hospital

• Escalations to North Central London Sector Wide System Leadership Forum to discuss and review issues affecting NCL providers as a Cancer System

• University College London Hospital participates in the system wide bilateral meetings to improve Inter Trust Transfer pathways.


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Subject



Cancer WaitingTimes

62 Day Screening Standard: In January 2018, University College London Hospital achieved a performance of 81.3% against the 90% threshold

62 Day Consultant Upgrade Standard: University College London achieved a performance of 69.8% against Camden CCG set threshold of 90%.

NCEL Actions:

The North Central & East London Performance Leadership Group closely monitors provider cancer waiting lists, including performance against the inter-trust transfer target of 38 days for onward referral and 24 days for treatment at a secondary Trust.

• Series of tumour specific bilateral meetings across NCEL commenced November 2017

• Reduction of gynaecology 2 week wait to day 7

• Reduction of skin 2 week wait to day 7

• Delivery of treatment within 24 days of receipt of tertiary referral

• Delivery of neck lump ultrasound at first appointment

• Improving head and neck Inter Trust Transfer pathway

• Embedding Optimal Lung Timed Pathway

• Increasing e-referral two week slots.

• Continuous review of action plans submitted by University College London Hospital at the CCG / University College London Hospital monthly integrated performance meetings.

• Weekly attendance at University College London Hospital Cancer PTL Meetings or consider instigating weekly teleconference to discuss University College London Hospital PTL position and performance

• Specialised commissioning to support Positron Emission Tomography and Computerised Tomography scan capacity in NCL.


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58

University College London Hospital Quality Dashboard

Theme UCLH: KPI/Measure Reporting Period

Actual performance

2017-18 YTD

Trend Blue = Actual Red = Target

Number of complaints 2017-18 Quarter 3 217 652

New Number of acquired pressure ulcers: Grades 3 & 4(Safety Thermometer) Feb-18 2 32

Old Pressure ulcers that are present on admission 3 & 4(Safety Thermometer) Feb-18 6 113

The number of patients falls with severe harm (target = 0)(as per NPSA definition - Safety Thermometer) Feb-18 0 1

Number of Never Events (target = 0) Feb-18 0 0

Serious Incidents (SIs) Number Reported (Provisional figures, due to potential de-escalation)

Feb-18 2 33

Number of MRSA Bacteriaemia Jan-18 0 1


Average fill rate - Registered nurses/midwives (Day) Dec-17 91.61% n/a

Average fill rate - Registered nurses/midwives (Night) Dec-17 94.04% n/a

Average fill rate - Care staff (Day) Dec-17 121.62% n/a

Average fill rate - Care staff (Night) Dec-17 137.48% n/a

Patient Safety

187 209 224 210 204 139 184 185 180 228 190 245 217

0 1 1 0 1 0 0 10 0 0 1

21 0 0

11

5 7 63 2 0

3 3 2

106 6 5 6

0

0 1 0 0 0 0 0

21 1 1 0

103.6% 100.2% 97.5% 94.6% 92.2% 95.6% 94.63% 93.26% 94.86% 96.07% 92.34% 95.08%

105.6% 103.9% 104.1%98.2% 98.4% 100.4% 98.83% 97.69% 99.87% 99.26% 97.75% 97.42%

124.73% 122.80%125.79% 127.45%

129.50%

126.97%

124.12%

121.01% 121.62%

156.7% 159.3% 150.3% 142.7% 147.0% 144.4% 145.59% 141.03% 144.80% 139.83% 136.06% 135.40%

0 0 0 0 0 0 0 0 0 0

0

1 1

0 0 0

94.06% 93.09% 92.02%90.34%

88.52%90.45%

93.06% 93.28% 91.61%

94.06%96.70%

94.17% 93.00% 92.22%94.28% 95.77% 96.30%

94.04%

123.48%

136.38% 139.27% 138.17%143.87% 144.14%

136.16%140.40% 137.48%

21

0 01

0

65

6

0

21

15

8

7 6 6 6 52

10

14 13 10 9 116 8

146

166

63 2 3 2 1

30

5 5

2

0 0 0 0 0 0 01

01

06 5 6

02 1

421

0 01

00 0 0 0 0 0 0 0 0

31 1

42 1 2 2 1 8 2

61

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59

University College London Hospital Quality Dashboard

Theme UCLH: KPI/Measure Reporting Period

Actual performance

2017-18 YTD

Trend Blue = Actual Red = Target

VTE (% admitted patients assessed for VTE risk) Sep-17 96.04% 95.54%

Proportion of patients spending 90% of their stay on a stroke unit - HASU (Routinely admitting team)

Apr to July 2017/18 80.30% n/a

60% of patients presenting with stroke with AF anti-coagulated on discharge HASU (Routinely admitting team)

Apr to July 2017/18 100.00% n/a

Stroke - 95% patients admitted to stroke unit within 4 hours - HASU (Routinely admitting team)

Apr to July 2017/18 53.70% n/a

70% of applicable patients who were given a formal swallow assessment within 72h of clock start - HASU (Routinely admitting team)

Apr to July 2017/18 97.80% n/a

Friends & Family test (FFT) - % Recommended - Inpatients Jan-18 93.57% n/a

Friends & Family test (FFT) - Response Rate - Inpatients Jan-18 19.09% n/a

Friends & Family test (FFT) - % Recommended -A&E Jan-18 82.35% n/a

Friends & Family test (FFT) - Response Rate - A&E Jan-18 13.05% n/a

Friends & Family test (FFT) - % Recommended - Out Patients Jan-18 92.36% n/a

Friends & Family test (FFT) - Response Rate - Outpatients Jan-18 11.01% n/a

Maternity Friends & Family test (FFT) - Question 1 % Recommended (Antenatal Care) Jan-18 94.34% n/a

Maternity Friends & Family test (FFT) - Score Question 2 % Recommend (Birth) Jan-18 97.44% n/a

Maternity Friends & Family test (FFT) - Score Question 3 % Recommend (Post Natal Ward) Jan-18 93.57% n/a

Maternity Friends & Family test (FFT) - Score Question 4 % Recommend (Post Natal Community Provision) Dec-17 91.67% n/a

Staff Friends & Family test (FFT) - % Recommended as a place to work Q2 2017/18 70.97% n/a

Staff Friends & Family test (FFT) - % Not Recommended as a place to work Q2 2017/18 13.21% n/a

Staff Friends & Family test (FFT) - % Recommended as a place for Care Q2 2017/18 90.01% n/a

Staff Friends & Family test (FFT) - % Not Recommended as a place for Care Q2 2017/18 3.85% n/a

Mixed sex Accomodation Breaches Jan-18 39 311


Patient Experience

94.97%96.57%

93.28%

92.62% 93.21%

92.28%94.67% 93.52%

93.57%

95.47%

17.05% 19.48% 17.90% 18.83%23.68% 19.82% 19.75% 18.88% 17.48% 19.09%

94.9% 96.1% 97.0% 97.9% 96.8% 96.4% 96.1% 99.52%93.08% 95.19% 93.86%

97.81% 97.98%

91.7%89.4%

91.8% 92.6% 94.1%88.3% 87.9% 87.50%

90.34%94.33% 92.86% 92.79% 90.63%

12 721

25

3046 37

52 42 39

98.0% 95.5%100.0% 100.0% 98.2% 98.2% 100% 100% 100% 100%

96.43%100.00%

97.30%

72.9%69.6% 67.5%

70.65%

95.27%96.12%

95.24%96.04%

3.3% 6.1%

4.1% 4.08%

12.3%16.99% 17.12% 16.3%

90.3% 88.5% 90.1% 92.39%

86.9% 87.0% 84.9% 85.7%91.8% 91.7% 91.4% 91.4% 93.93% 95.24% 94.41% 94.64% 94.15%

33.9% 36.5%30.3% 29.8%

18.5% 19.8% 19.5% 15.83%

31.02%26.19%

21.41%29.40%

18.50%

89.8%93.6% 92.5%

89.8%93.7%

97.8%93.9% 93.81%

88.65%

96.40%94.03% 93.58% 94.24%

89.58%80.39%

85.80% 81.54% 82.33% 80.35% 84.03% 82.00% 83.10% 82.35%

8.07%18.25% 13.41% 11.93% 12.74% 11.34% 14.04% 14.45% 14.45% 13.05%

26.7% 30.4% 34.5% 34.9% 31.1% 26.8% 25.4%32.82% 28.02% 32.50% 39.14% 38.24%

23.90%

88.89% 93.14% 0.00% 0.00% 0.00%98.25% 92.13% 91.67% 94.34%

99.12% 99.01%

0.00%

97.52% 98.91% 98.81% 96.00% 97.14% 97.44%

26.7% 30.4% 34.5% 34.9% 31.1% 26.8% 25.4%32.82% 28.02% 32.50% 39.14% 38.24%

23.90%26.7% 30.4% 34.5% 34.9% 31.1% 26.8% 25.4%32.82% 28.02% 32.50% 39.14% 38.24%

23.90%

95.38% 87.88% 0.00% 92.91% 95.51% 93.02% 93.98% 98.59% 93.57%

26.7% 30.4% 34.5% 34.9% 31.1% 26.8% 25.4%32.82% 28.02% 32.50% 39.14% 38.24%

23.90%

0.00%0.00% 100.00%

100.00% 100.00% 95.24% 100.00% 91.67%

77.7% 75.0% 84.3% 78.0% 85.4% 90.5% 84.40% 71.20%87.31% 80.10% 68.40%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

56.20% 51.80% 61.50% 51.00%66.90% 71.20%

55.90% 35.50%63.11%

45.90% 34.20%

80.50% 81.70% 90.90% 91.30% 86.90% 94.00% 82.10% 88.50% 96.41% 95.50% 97.00%

93.52%

93.84%

92.11%

91.14%

91.55%

90.39%

91.38% 91.22% 90.97% 92.36%

18.50%22.93% 22.07% 19.77% 22.80%

1.58% 1.92%

17.98% 12.48% 9.70%6.41%

10.19% 12.36%8.17%

11.01%

26.7% 30.4% 34.5% 34.9% 31.1% 26.8% 25.4%32.82% 28.02% 32.50% 39.14% 38.24%

23.90%72.9% 69.6% 67.5% 70.65% 60.34% 66.74% 74.23% 71.43% 66.67% 70.86% 70.97%

26.7% 30.4% 34.5% 34.9% 31.1% 26.8% 25.4%32.82% 28.02% 32.50% 39.14% 38.24%

23.90%12.3% 16.99% 17.12% 16.3%

23.46% 17.77% 12.78% 13.53%20.97%

12.59% 13.21%

26.7% 30.4% 34.5% 34.9% 31.1% 26.8% 25.4% 32.82% 28.02% 32.50% 39.14% 38.24% 23.90%90.3% 88.5% 90.1% 92.39% 87.71% 88.22% 92.07% 88.91% 87.50% 91.41% 90.01%

26.7% 30.4% 34.5% 34.9% 31.1% 26.8% 25.4% 32.82% 28.02% 32.50% 39.14% 38.24% 23.90%3.3% 6.1% 4.1% 4.08% 3.91% 4.75% 3.52% 3.50% 6.52% 2.86% 3.85%

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University College London Hospital Quality Summary


Subject

Description of Issues Actions and progressNEL CSU

recommendations

Serious Incidents (SIs)

Two Serious Incidents were reported in February 2018 which related to:

- Maternity/Obstetric incident meeting Serious Incident criteria: mother and baby (x1)

- Sub-optimal care of the deteriorating patient (x1)

Two Serious Incident investigation reports have not been submitted within deadline and are overdue as at the end of February 2018.

University College London Hospitals NHS Foundation Trust provide a monthly Serious Incident report to the Clinical Quality Review Group

The University College London Hospitals NHS Foundation Trust provide a quarterly assurance report against the Duty of Candour requirements

NHS Improvement issued a revised Never Events Framework, effective from 01 February 2018.

Assurances were provided to the Clinical Quality Review Group on 6 March 2018 that these changes have been cascaded to all clinical staff and the relevant policies have been updated as a result.

NEL Commissioning Support Unit and Camden Clinical Commissioning Group to actively monitor progress against each Serious Incident and request status updates against the longest overdue Serious Incidents at Clinical Quality Review Group.

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Subject

Description of Issues ActionsNEL CSU

recommendations

Meticillin-resistant

Staphylococcus aureus and Clostridium

difficile

Meticillin-resistant Staphylococcus aureusThere has been one Meticillin-resistant Staphylococcus aureus bacteraemia against an ambition of zero for this financial year to date. The likely source was associated with a peripherally inserted central catheter and all recommendations and actions identified in the post infection review have been implemented.

Clostridium difficileUniversity College London Hospitals NHS Foundation Trusts latest validated position reports ten Clostridium difficile case in January 2018. The total trajectory for 2017/18 is 97. The year-to-date position is of 56 reported cases.

Root cause analyses continue to be completed jointly with the multidisciplinary team within 10 days and are being discussed on a monthly basis with Camden Clinical Commissioning Group to identify any lapses in care.

University College London Hospitals NHS Foundation Trust provide a quarterly assurance report to the Clinical Quality Review Group quarterly.

University College London Hospitals NHS Foundation Trust and NEL Commissioning Support Unit / Camden Clinical Commissioning Group jointly agree the outcome of the Root Cause Analysis to determine lapse of care. All learning is reported at Clinical Quality Review Group as part of the quarterly agenda item.

An example of changes from learning include the multidisciplinary C. difficile weekly ward round reviewing the progress of all C. difficile toxins and antigen cases admitted as inpatients. Identification of early signs of relapses and poor treatment response have been the key issues managed to date.

• Clinical Quality Review Group to continue to closely monitor Infection Control compliance and hold detailed quarterly discussions at Clinical Quality Review Group.

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62


Subject

Description of Issues Actions NEL CSU recommendations

Mixed Sex Accommodation

University College London Hospitals NHS Foundation Trust have reported 30 Mixed Sex Accommodation breaches in February 2017.

26 of these breaches were reported for the University College Hospital site and four were reported at the Queen’s Square site.

Daily Site Management meetings take place, in which capacity and demand in relation to Mixed Sex Accommodation and preserving patients dignity is discussed.

• University College London Hospitals NHS Foundation Trust have not received any complaints or concerns from patients in relation to Mixed Sex Accommodation breaches.

• Commissioners / NEL Commissioning Support Unit to monitor monthly reports against Mixed Sex Accommodation breaches to Clinical Quality Review Group and any complaints relating to Mixed Sex Accommodation breaches.

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63


Subject

Description of Issues Actions NEL CSU recommendations

Quarter 3 Patient

Experience and

Complaints

The Quarter 3 report was presented to the March Clinical Quality Review Meeting.

It is recognised that University College London Hospital have continued to make improvements in relation to patient experience, challenges remain in the following areas;

- Communication- Waiting times- Hospital Transport

Commissioners have identified issues with transport services as a recurring theme within complaints and incidents.

There are a number of work streams in place to address the issues identified regarding communication and waiting times, which are monitored at Divisional level and reported into the Patient Experience Committee.

Patients are reporting positive feedback on NHS Choices in relation to;- Clinical care and treatment- Staff attitude

Transport services across the Trust are provided by a third party, G4S. The Trust executive team have reviewed these issues and in response, have strengthened key performance indicators (KPIs) and monitoring arrangements.

Commissioners / NEL Commissioning Support Unit to seek assurance through quarterly patient experience reports to Clinical Quality Review Group

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University College London HospitalQuality Summary


Subject


recommendations

Delay to Treatment:

Clinical Harm Review

Referral To Treatment – January 2018:There were three patients waiting >52 weeks at January 2018 month end in Neurosurgery and one in Neurosurgery. Clinical harm reviews have not identified harm.

To date no patient harm was identified relating to extended Referral To Treatment pathway waits.

University College London Hospitals continues to track all patients waiting 35 weeks and above at the Patient Tracking List meetings in order to identify actions to prevent any patient reaching 40 weeks. Actions are followed up weekly with each service. All patients previously reported as having waited beyond 52 weeks have now received treatment.

62 Day Cancer standard – December 2017• University College London Hospitals NHS

Foundation Trust reported 14 breaches, five internal and nine external (which is 23 patients as each external treatment counts as a half).

• University College London Hospitals NHS Foundation Trust undertook RCAs and clinical harm reviews for all patients who experienced a delay to treatment. In all cases no harm has been identified.

Agreed process in place to report assessment of clinical harm of patients that have extended waits for elective treatment.

Each month University College London Hospitals undertake a root cause analysis and clinical harm review for every patient whose treatment breached the 62 day treatment standard. University College London Hospitals share the full anonymised versions of the reviews with Camden Clinical Commissioning Group and NEL Commissioning Support Unit on a monthly basis.

Waiting times is a key risk noted on University College London Hospitals risk register for adequate monitoring.

University College London Hospitals re monitoring their recovery plan through the Camden Clinical Commissioning Group Integrated Performance Meeting and Contract Review Group.

Progress reporting on outcomes of the clinical harm review remains a substantive item for assurance on each Clinical Quality Review Group agenda.

University College London Hospital undertake breach analyses and clinical harm reviews for all patients who experienced a delay in treatment.

Monitor for clinical harm and adverse patient experience

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Subject


recommendations

Cancer Quarterly

Discussion

The Trust continue to be non-compliant with the 62-day standards (for GP referral – all cancers and 62-day screening –all cancers) across Q1, Q2 and Q3 2017/18.

University College London Hospital has a low level of compliance against cancer staging data. Teams are not consistently providing updates leading to a potential source of errors and incorrect data reported via the Registry and on infloflex (cancer data system).

The Trust state that all 62 day breaches including all breaches over 100 days have a breach analysis undertaken, as part of the Clinical Harm Review process. University College London Hospital have assured Clinical Quality Review Group that no clinical harm as a result of the breaches, has been identified to date.

The Trust Quality and Safety team have reviewed the cancer clinical harm review guidelines to ensure a consistent approach is undertaken by all services. These guidelines are now being reviewed by senior management prior to signoff and implementation.

Work on national best practice pathways is underway with work being led by the cancer vanguard. New timed pathways are being developed and implemented to support making a diagnosis by day 28 in line with the changes to cancer waiting standards.

University College London Hospital have taken part in bilateral meetings with other providers for shared pathways with highest numbers of breach volumes. These have led to the production of bilateral action plans which are being overseen by the sector performance leadership group and a refreshed overall trajectory.

Clinical Quality Review Group to continue to closely monitor quality of Cancer services and hold detailed quarterly discussions at Clinical Quality Review Group.

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Subject


recommendations

Cancer Quarterly

Discussion

62 Day Standard

Internal performance issues and risks:

• Medical complexity: This continues to be a cause of breaches and while we can reduce will still see some breaches.

• Patients choosing to delay diagnosis and treatment still continue to cause breaches.

External performance issues and risks:• Risks to achievement of the overall standard for shared pathways continue due the still receiving patients after day 38.

62 Day Standard - Internal Performance:

• Medical Complexity: UCLH continue to reduce this through close tracking and escalation especially in the early part of the pathway.

• Patients choosing to delay diagnosis and treatment: UCLH have identified actions such as extra support from members of the clinical team in decision making, patient leaflets on expectations within the urology pathway.

• UCLH have instigated a zero tolerance for breaches for avoidable reasons and have produced a number of operational reports to assist in identification of at risk patients lower down the pathway.

62 Day Standard - External performance issues and risks:University College London Hospital has taken part in bilateral meetings with other providers for shared pathways with highest numbers of breach volumes. These have led to the production of bilateral action plans which are being overseen by the sector performance leadership group and a refreshed overall trajectory.

Clinical Quality Review Group to continue to closely monitor quality of Cancer services and hold detailed quarterly discussions at Clinical Quality Review Group.

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Performance against Quality and Performance KPIs

NCL Integrated Urgent Care Service (IUC)

70

Data Source: LCW Reports

Data Source: LCW Reports There is a similar pattern to the types of call response for each CCG with most patients being supported by speaking to the call advisor.

Types of activity by CCG

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18NCL-IUC NCL-IUCNCL-IUCNCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC NCL-IUC

Engaged calls Performance 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Abandoned calls Performance 0.4% 0.9% 0.8% 1.4% 1.5% 3.0% 3.2% 4.8% 3.5% 4.7% 8.5%Answer Time Performance 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%Call waiting time Performance 95.6% 91.0% 91.2% 86.3% 88.3% 81.6% 80.5% 73.3% 77.4% 76.7% 62.6%Life threatening referrals Quality 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%Meeting individuals needs Quality 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%Safeguarding Quality 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%Triage rate Quality 106.6% 108.1% 108.2% 106.4% 104.9% 104.0% 109.1% 106.8% 104.2% 104.4% 103.5%Transfer to 999 Performance 9.6% 9.7% 10.3% 10.4% 10.9% 11.7% 11.5% 11.6% 11.7% 12.0% 12.3%Attend Accident & Emergency Department Performance 9.4% 9.8% 10.1% 10.5% 9.4% 10.1% 10.0% 9.8% 9.0% 10.2% 10.3%Referred to Primary Care and other dispositions Performance 55.5% 52.8% 52.5% 52.9% 51.9% 51.0% 51.5% 51.9% 55.4% 55.3% 56.6%Warm Transfers Performance 68.1% 66.0% 68.0% 71.6% 73.8% 66.5% 73.3% 72.2% 72.4% 78.5% 80.7%Time taken for call back Performance 10.6% 13.1% 10.8% 54.6% 54.0% 53.5% 49.1% 48.7% 46.9% 44.8% 37.6%Notifications Quality 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%Patient Education Quality 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Qrt4Qrt 2Qrt 1Quality and Performance Indicators KPI Type Qrt3

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IUC Activity Outcomes by Type and Patient Age Profile


71Data Source: LCW Reports

Age profile of patients supported by LCW IUC service during February 2018

Data Source: LCW Reports

9 IUC Outcomes9.1 Count of outcomes of ambulance dispatch 30849.2 Count of outcomes of recommended to attend A&E 32469.3 Count of outcomes of recommended primary or community care 101489.4 Count of outcomes of recommended to contact primary medical care 48969.5 Count of outcomes of recommended to contact community care 1539.6 Count of outcomes of recommended to dental 7739.7 Count of outcomes of recommended to pharmacy 2379.8 Count of outcomes of recommended to attend other service 5489.9 Count of outcomes of not recommended to attend other service 36839.1 Count of outcomes of given health information 30849.11 Count of outcomes of home care recommend 22429.12 Count of outcomes of non-clinical 4089.13 Count of outcomes of mental health service 57

Caller GroupVolume % Volume % Volume % Volume % Volume % Volume %

Group 1 (total) 8819 5037 7410 6126 4765 32157SPNs 12 0.1% 17 0.3% 18 0.2% 14 0.2% 10 0.2% 71 0.2%Patients 80 years and older 1654 18.8% 460 9.1% 711 9.6% 548 8.9% 354 7.4% 3727 11.6%Patients under 5 years old 1130 12.8% 610 12.1% 1111 15.0% 830 13.5% 620 13.0% 4301 13.4%All other patients 5167 58.6% 3528 70.0% 4804 64.8% 4070 66.4% 3326 69.8% 20895 65.0%Repeat callers 856 9.7% 422 8.4% 766 10.3% 664 10.8% 455 9.5% 3163 9.8%

Haringey Islington TotalBarnet Camden Enfield

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Key Issues Priority Actions

A Serious Incident occurred at London Central West Unscheduled Care Collaborative in April 2017. An undercover journalist from The Sun newspaper made a number of allegations about the integrated urgent care service.

London Central West Unscheduled Care Collaborative are meeting all of the agreed national and local key performance indicators apart from call waiting time (62.6%) and Abandoned Calls (8.5%). This is due to London Central West Unscheduled Care Collaborative having faced a number of staffing challenges following the April 2017 serious incident coupled with increased activity levels. There has not been any clinical risk to patients, however there have on some shifts been fewer staff resulting in call waiting times increasing above the agreed target, coupled with increased abandonment rates.

It was agreed as part of the roadmap that the call waiting time key performance indicator is reduced to 85%, with a transition to average answer time.

NHS England requested a commissioner initiated external review to investigate the serious incident. This was led by Professor David Colin Thome. An Extraordinary Clinical Quality Review Group took place on 16 February 2018 to review the findings of the report. It concluded that neither the internal investigation nor the Independent Investigation Team identified harm or detriment to patients; neither did the investigations reveal significant risks or issues relating to the delivery of ongoing services. London Central West Unscheduled Care Collaborative provided an update on the serious incident at Clinical Quality Review Group on 23 March 2018, advising that most actions are now closed. Enfield CCG have prepared a report to be shared with NCL and INWL CCGs at the appropriate Governing Body meetings. An update will be provided at the May 2018 Clinical Quality Review Group.

London Central West Unscheduled Care Collaborative performance for the Call Waiting Time metric has dropped in February 2018, however this is an issue across London, with no London provider meeting this indicator or the abandoned calls indicator. London Central West Unscheduled Care Collaborative is carrying out further analysis to better understand the drivers of the increase in abandoned calls. They suggested that the data could be skewed by patients who end calls early to access the online service instead (Babylon) and are liaising with Health London Partnership to understand this. London Central West Unscheduled Care Collaborative analysis will be presented to commissioners at the April 2018 Clinical Quality Review Group.

A Contract Technical Group has been set up to review finance and activity levels against the agreed contract baseline to understand the drivers of the increased activity. A finance & activity report is being developed to highlight London Central West Unscheduled Care Collaborative financial pressures. A Key Performance Indicator Task and Finish Group has been set up to review and agree the suite of national and local key performance indicators.

The cost improvement roadmap has been progressing, with weekly meetings with commissioners and London Central West Unscheduled Care Collaborative. Current areas of focus include the closure of the Primary Care Centre bases at weekends and the deployment of black pear interface, to allow appointments to be booked directly into hubs. A paper is going to Senior Management Team on 27 March 2018, to agree the next phases of the roadmap.


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London Ambulance Service Performance

70

Data Source: LAS Performance ReportThe four new patient categories are:Category 1 – Life Threatening (8% of calls) Category 2 – Emergencies (48% of calls) Category 3 – Urgent (34% of calls) Category 4 – Less Urgent (10% of calls).

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NCL Ambulance Service Quality and Performance

74


Following the introduction of the Ambulance Response Programme, performance reporting is under review across the organisation and in conjunction with commissioners. Due to this on-going review the new formal contract reports have not yet been formally agreed.

A new Tri-Partite report will continue to measure activity by category and record hospital conveyances. Four key reports will contribute to data for the Tri-Partite. To be shared.

NEL Commissioning Support Unit will continue to attend Contract and Performance meetings to activity monitor performance of the Ambulance Review Programme and other key KPI’s.

There are a small number of problems that will be shared with local management teams to decide/agree on resolution. Commissioners and NEL Commissioning Support Unit will continue to monitor and feedback on progress.

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NCL Ambulance Service Quality and Performance

72 of 7272


Ambulance TetheringThe New Dispatch Model Trial was set up as part of a NCL improvement programme in response to an inequity of ambulance performance between sectors. The trial ran for nine weeks between 16 August 2017 and 17 October 2017 and consisted of three elements:

North Central Dispatch Group: Dedicated allocators/dispatchers & a solo responder desk;Ambulance tethering: emergency ambulances based in North Central would only be dispatched to incidents occurring within their home sector (except Red 1 incidents);New Fast Response Unit end of shift process: Ambulance staff guaranteed a rest break during the course of their shift.

The outcomes of the pilot were as follows: Category A response times were largely unchanged while Category C response times reduced;No significant association was found between the New Dispatch Model Trial and conveyance rates.

While it had been hoped that the New Dispatch Model Trial would result in greater equity of performance between CCGs in North Central, this was not identified in the results. Job Cycle time remained largely unchanged in the New Dispatch Model Trial group with no clear change within any element.

The end of shift trial was generally well received by solo responders with significant feedback citing that less late finishes and more rest breaks had a positive impact on morale.

A number of recommendations have been made by the New Dispatch Model Trial group which the Trust is currently considering. These include:

The Emergency Operations Centre to be permanently reconfigured to align with the STP geographical boundaries;

A formal end of shift process to be considered as part of new rest break arrangements;

Ambulance tethering to be permanently implemented for Category 3 and Category 4 patients. For Category 2 patients, it is recommended that dispatchers should attempt to dispatch a local vehicle first, but if unable to assign after 8 minutes, any ambulance should be dispatched;

Consideration to be given to extending the open channel function on Airwave radios taking into account cost, benefit and utility.

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Quality Assurance Sign-off

Section Written By

Performance Mark Bridgeford

Quality Helena Sage

NHS111, GP Out of Hours & LAS Contracts Greg Hudson/Emmet Masterson

Final Sign Off By: Helen BoswellDate: 10/04/2018

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74Back to list

To know moreIf you would like to discuss any elementsof this presentation, please contact ourPerformance team on:Email: [email protected]

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Item: 3.4 MEETING Islington CCG Governing Body

DATE 9th May 2018

REPORT Request to Delegate Authority for Approval of the Annual Report and Accounts to the Islington CCG Audit Committee

LEAD DIRECTOR Tony Hoolaghan, Chief Operating Officer AUTHOR Emer Delaney, Head of Communications and Engagement, Haringey CCG

and Islington CCG Karl Thompson, NCL Head of Corporate Services

CONTACT DETAILS [email protected] [email protected]

EXECUTIVE SUMMARY All NHS bodies have a statutory requirement to produce an Annual Reports and Accounts (ARA) as a single document. Islington CCG has adopted the template issued by NHS England (NHSE) for the 2017-2018 financial year, which contains the following required sections. 1. The Performance Report: an overview and a performance analysis. 2. The Accountability Report: Corporate Governance Report, Remuneration and Staff Report and

a Parliamentary Accountability and Audit Report. 3. The Annual Accounts: including financial statements.

Draft submissions of the ARA were required by 20th April 2018. The Haringey and Islington Executive Management team reviewed the organisation’s draft ARA at its meeting on 18th April. The meeting agreed a number of changes, and members along with CCG lay members have been given until 4th May to make any further comments (see Table 1 for the drafting and approval timeline). As in previous years, it is proposed that authority to approve the final submission is delegated to the CCG Audit Committee; to be discharged at is meeting on 22nd May 2018. Table 1: National and Local Timelines Date Actions

April 2018

Friday 20 April (noon)

CCGs to submit: • Draft annual report as approved by the Accountable Officer (and passed to appointed

auditors for audit). • A full copy of the draft Head of Internal Audit Opinion statement as issued by the CCG’s

internal auditors. To include a list of all audit reviews undertaken, and the level of assurance assigned to each review.

• Completed NAO disclosure checklist 2017/18 for draft submission

May 2018

22 May Final draft of the ARA to be considered by the CCG Audit Committee

Tuesday 29 May (noon) Note: Monday 28 May is

CCGs to submit: • Full audited ARA, signed and dated by the Accountable Officer and appointed auditors,

as one composite document. • A full copy of the final Head of Internal Audit Opinion statement as issued by the CCG’s

internal auditors. Submitted a separate document. Summary version included in the ARA. • Completed NAO disclosure checklist 2017/18 for final submission

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a Bank holiday

June 2018

By 15 June

CCGs to publish their ARA in full on their public website.

September 2018

By 29 Sept

The ARA will be presented in public at a Islington CCG Annual General Meeting

Member statement As part of our preparation and sign off of the annual report and accounts, whilst the Governing Body have delegated responsibility for the documentation to be signed off at the Audit Committee, each individual who is a member of the Governing Body at the time the Members’ Report is approved, is asked to confirm the following:

• so far as the member is aware, there is no relevant audit information of which the CCG’s auditor is unaware that would be relevant for the purposes of their audit report

• the member has taken all the steps that they ought to have taken in order to make him or herself aware of any relevant audit information and to establish that the CCG’s auditor is aware of it.

Governing Body Members are asked to confirm they are happy to support this statement.

RECOMMENDED ACTION: The Governing Body is asked to:

• DELEGATE authority for the approval of the final ARA submission to the CCG Audit Committee.

• NOTE members response to the disclosure to auditors statement

Patient & Public Participation (PPP): Audit Committee membership includes lay members. Equality Impact Assessment: Not required Risks: As outlined in the CCG’s assurance framework and risk register Resource Implications: None identified at present

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of 5

MEETING: Islington CCG Governing Body

DATE: 9 May 2018

TITLE: RAF Report

LEAD COMMITTEE MEMBER: Alex Smith Director Planning Performance and Delivery Haringey and Islington (H&I) CCGs

AUTHOR: Vivienne Ahmad, Board Secretary, Islington CCG

CONTACT DETAILS: [email protected] SUMMARY: This report presents the Risk Assurance Framework (RAF) following an alignment of the current risks into Islington CCG’s Objectives and clarifies movement with key strategic risks during Quarter 1, providing an insight in to the current level of risk likely to impact on the achievement of Islington CCG’s strategic objectives:

• Ensuring every child has the best start in life; • Preventing and managing long term conditions to extend both length and quality of

life and reduce health inequalities; • Improving mental health and wellbeing; • Delivering high quality, efficient services within the resources available.

This framework should be considered in conjunction with the:

• NCL (North Central London CCGs) Strategic Risk Register • PCCC (Primary Care Committee in Common) Risk Register • NCL JCC (Joint Commissioning Committee) Risk Register

Prior consideration by Committees and other partners: Specific elements of the RAF were considered by the Strategy and Finance Committee on 24 April 2018 and the Quality and Performance Committee on 26 April 2018. Patient & Public Involvement (PPI): This paper will be available on the CCG website for consideration by patients and public. Relevant risks will be reviewed by the PPP Committee on 3 May 2018 and further reviewed by the Chair of the PPP Committee and the Chief Operating Officer. Equality Impact Assessment: not required for summary report.

Item: 4.1

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Risks: N/A RECOMMENDED ACTION: The Governing Body is asked to:

• NOTE and COMMENT on the latest iteration of the RAF document

SUPPORTING PAPERS: 4.1.1 - Islington CCG Risk Assurance Framework - April 2018 4.1.2 - NCL Joint Commissioning Committee Risk Register - April 2018 4.1.3 - Primary Care Committee in Common Risk Register April 2018 4.1.4 – NCL Risk Register - April 2018 4.1.5 – Risk Scoring Key

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Islington CCG Audit Committee Risk Assurance Framework

LATEST MOVEMENT IN THE RISK ASSURANCE FRAMEWORK New Risks There was one new risk added to the RAF since the last meeting. Risk 437 (score 15) – 2018/19 QIPP Programme Delivery – Previous QIPP risk of 2017/18 was risk ID 409 which has been recommended to close. This new risk 437 would be discussed at Strategy and Finance Committee on 26 April 2018. Risk Movement Risk 428 (score 12) – Medicines Management - The recommendation is to reduce the risk rating from 16 to 12 given that recent reporting has shown a decline in the financial impact of NCSOs. Risks Closed The following risk is proposed for closure: Risk 409 (score 12) – 2017/18 QIPP Programme Delivery - It is recommended to close this risk as the new 2018/19 QIPP Risk has been opened - risk number 437.

BACKGROUND & CONTEXT Principal Risks

The RAF document is focused on the principal risks to the achievement of our strategic objectives, by this we are referring to risks that if not managed effectively will result in our failure to deliver against each objective. Principal risks have therefore been defined as those with an inherent risk score (before mitigation) of 15+ (red risks).

It can be assumed that risks with inherent risk scores lower than 15 are not on their own likely to result in our failure to achieve an objective. These risks are still important though and will be managed through our corporate risk register but will not feature in the RAF.

High Residual Risks

There may be instances where risks not inherently scored as high escalate due to further circumstances arising. Once these risks are reassessed as high risk, they are brought in to the RAF for consideration by the Governing body.

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NCL Joint Commissioning Committee Risk Register The NCL Joint Commissioning Committee (‘NCL JCC’) risk register has 7 risks with a current risk score of 15 or higher and therefore are reporting them to the Governing Body to ensure visibility and oversight. These risks are from a pan NCL perspective and therefore there is some overlap with Barnet CCG only risks. Key Highlights JCC 1- Delivery of Cancer 62-day waiting time standard (Threat): NCL as a system delivered the standard in December 2017 but additional work is required for this to be sustainable. However, the individual recovery plan from UCLH defers their recovery of the standard from March 2018 to June 2018. Internal pathways are expected to be compliant in April 2018. JCC 10- Mobilisation of STP and QIPP plans (Threat): The in-housing of functions from NEL CSU into the CCGs is underway. This will provide greater support and capacity to deliver STP interventions. However, additional capacity is needed to progress the work on alternative contract forms. JCC 11- Managing Acute Contracts within Contract Baselines (Threat): Signed contracts with acute providers in place for 2017/18 and 2018/19 with respect to all the main contract terms other than baseline. Baselines predicated on growth have been agreed but discussions on STP interventions are on-going with providers until end of April 2018. The contracts operate under a marginal rate basis against the agreed baseline. This helps to mitigate risk for both providers and commissioners from variances in activity levels and incentivises both sides to reduce unnecessary and avoidable activity. NCL Primary Care Co-Commissioning Risk Register The NCL Primary Care Co-Commissioning Committee in Common (‘NCL PCC’) risk register has 1 risks with a residual risk score of 15 or higher and therefore this risk is being reported to the Governing Body to ensure visibility and oversight. Risks from the NCL PCC can be from either a local perspective or a pan NCL perspective depending on the risk. Risk 18- Primary Care Support England (Threat): The NHS England primary care support functions provided by NHS England and contracted to Capita have been significantly underperforming. This has led to a disruption in GP business continuity and potential cost pressures to CCGs. This risk is primarily managed by NHS England. NHS England meet with Capita regularly to try to resolve the issues and the NCL CCGs raise issues with NHS England at London primary care meetings.

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NCL Risk Register The NCL Risk Register captures the key pan NCL risks that are not captured by our other risk registers. The NCL Risk Register contains ten risks which include NCL and STP risks. The NCL Risk Register will be reviewed regularly by the NCL Senior Management Team, the STP PMO and the assurance process will be overseen by the NCL audit committees. Key Highlights NCL 4- Failure to Effectively Engage with Patients and the Public (Threat): A new Head of Communications for the STP has been recruited and will start in May 2018. NCL 8- Recruitment and Retention a High Performing Workforce (Threat): The NCL HR team has been fully recruited to with all team members being in place by end of June 2018. Recruitment for the Organisational Development roles is under way. NCL 9- Delivering Financial Balance across NCL CCGs (Threat): 2018-19 budget planning is underway and QIPP plans will be implemented throughout the year.

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Q4 Q1 Q2 Q3 Q4

Ensuring every child has the best start in life

Preventing and Managing Long Term Conditions to extend both length and quality of life and reduce health inequalities

Improving Mental Health and Wellbeing

205 Strategy & Finance

Pressure on mental health acute beds

If pressure/demand exceeds the current bed base provided by our commissioned services then

The CCG may not be able to meet its obligation to commission effectively to meet the health needs of our residents in terms of

• safety – through delayed admission and risk of stay on an excessively high occupancy ward

• Clinical effectiveness: care not based on health need or poor continuity of care

• Poor patient experience.

This could also adversely affect the CCG’s reputation.

20 9 9

Delivery of High Quality, Efficient Services Within Available Resources


NCL Commissioning Arrangements & Local Change Process

Uncertainty over the NCL commissioning arrangements and change process involving Haringey CCG, may occur as a result of a lack of clarity and tranparency over the organisation

structure and impact on individuals and teams. This could lead to loss of organisational knowledge from increased staff absenteeism/leaving and also the over reliance on interim staff

due to higher levels of vacancies.

20 8 8

419 Quality & Performance

Whittington Health - Quality of Community Service Provision

There are a number of community services which are performing poorly against current contract specifications relating to access.This increases the likelihood of harm, discomfort and

poor quality outcomes as a result of the longer waits.

20 12 12


Moorfields - standardisation of service provision

The lack of formally agreed service level (SLA) contracts acorss satelitte sites potentailly leads to poor service provision resulting from ineffective quality governance systems. This

inturn restricts the drive for improvement, standardising of practices and influencing of change which can lead to poor patient outcome and experience.

20 12 12


Moorfields - Safer Surgery checklist (WHO)

The failure to utilise the WHO safer surgery checklist may lead to inconsistent practices across sites which in turn increases the chances of never events occuring and patients being

exposed to harm or clinical incidents.

25 12 12


Moorfields - SI system adherence

A lack of adherence to the 2015/16 serious incident framework and failure to provide evidence over the completion of part 2 Duty of Candour, will lead to poor learning from incidents

and an increased likelihood of repeat occurrences. The likely result is a detrimental impact on the reputation of the CCG through a lack of feedback around meeting Duty of Candour and

an increase in poor patient outcomes.

20 12 12

No principal risks have currently been identified for this objective based on the criteria defined (15+ risk score)

18/19

Objective 4

Objective 1

Objective 2

Objective 3

No principal risks have currently been identified for this objective based on the criteria defined (15+ risk score)

Risk Movement

since last Qtr

GOVERNING BODY RISK ASSURANCE FRAMEWORK

SUMMARY April 2018

Inherent Risk

ScoreRisk Ref

Review

Committee Description

17/18

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Q4 Q1 Q2 Q3 Q4

18/19 Risk Movement

since last Qtr

Inherent Risk

ScoreRisk Ref

Review


17/18


Whittington Health - Lower Urinary Tract Symptoms (LUTS)

The Trust and Commissioners have agreed a phased reopening of the LUTs clinic as a tertiary service for adult patients subject to conditions set out by the NCL Joint CCG Commissioning

Committee in April 2018. There is a risk that the agreed specifcation for 2018/19 may not be met.

20 12 12

425Patient and Public

Participation

STP engagement

The STP covers a wider footprint with an increased number of partners. This could lead to engagement becoming less effective, with groups that experience high levels of deprivation

and inequalities potentially not being heard. This could jeopodise the relationship with the community and cause significant reputational damage for the CCG.

16 12 12

426 Quality & PerformanceCamden & Islington FT - Mr G external investigation outcome

Failure to deliver recommendations within the action plan, increases the likelihood of similar incidents occuring, with the potential for further safeguarding concerns.25 12 12


Islington (Borough Council and NHS Trust) and Camden and Islington FT Adult Safeguarding Process

The electronic drive is held by the Local Authority (London Borough of Islington) and shared with the Trust (Camden and Islington NHS Foundation Trust). In November 2017, it became

apparent that the drive contains lists of names, including safeguarding concerns, police referrals etc and the Trust were not accessing the list and were not aware of the list. There is no

electronic link between the LA and Trust system for safeguaridng adults. This could result in patients falling through the system unmanged, increasing the chances of safeguarding

concerns materialising.

12 12 12

Statutory Obligations and Core Business


17/18 QIPP Programme Delivery

The QIPP target is set at £11.749m, £5.2m of which is expected to be delivered through the STP. The STP QIPP programme is largely transformation which requires substantial changes to

models of care.

Any slippage in QIPP (or unidentified QIPP) will need an action plan in plan to recover the position and mitigate financial and performance risks to the organisation. Failure to achieve the

CCG QIPP plan is likely to impact on the organisation's ability to meet its financial control total for the year and, as a result, the NCL Financial Control Total.

20 12 12


Medicines Management

A significant national increase in the number of short supply high volume generic medicines (categorised as No Cheaper Stock Obtainable, NCSO in the Drug Tariff) has created an

unpredictable rise month on month in the cost of these items. As a result, the CCG has predicted a potential additional overspend for these medicines in excess of £1.4m.

This is a national issue being managed by NHS England and the Department of Health. NHS England has published the guidance ''Refreshing NHS plans for 2018/19", which makes it clear

that CCGs should assume that the high level of discretionary prices for generic drugs in short supply will not persist in 2018/19.

20 16 12


Primary care workforce development

If the CCG is ineffective in developing the primary care workforce then this may have an adverse impact on the delivery of the primary care strategy. This could mean for example,

patients with long term conditions are not fully supported in primary care and require more frequent hospital care.12 12 12


Re-development of St Pancras site

Delayed start of consultation, failure to gain assurance from NHSE on process, threat of judicial review, not enough capacity to carry out a more thorough public consultation and

currently no support from Clinical Senate for clinical proposals, means the whole re-development of the St Pancras site is at risk.15 12 12


2018 / 19 QIPP Programme Delivery

The QIPP target is set at £12.6m net savings. The QIPP programme is largely transformational which requires substantial changes to models of care. Agreement as to the level of QIPP

contained within provider contracts as part of STP initiatives has not concluded in March 2018 and the contract with Whittington Health is subject to mediation. The outcome of

mediation is that Clinical Review sessions are taking place between commissioners and providers to be concluded by 30/4/18. Contractual agreement regarding levels of QIPP within

provider contracts is one of the key mechanisms to delivering QIPP savings.

Any slippage in QIPP, will need an action plan in place to recover the position and mitigate financial and performance risks to the organisation. Failure to achieve the CCG QIPP plan is

likely to impact on the organisation's ability to meet its financial control total for the year, and as a result, impact on the NCL Financial Control Total.

20 15

Other

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No principal risks have currently been identified for this objecitve based on the criteria defined (15+ risk score)

Objective 1 Ensuring every child has the best start in life

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Objective 2 Preventing and Managing Long Term Conditions to extend both length and quality of life and reduce health inequalitiesNo principal risks have currently been identified for this objecitve based on the criteria defined (15+ risk score)

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Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total

RAF Ref:

2054 5 20 3 3 9

Control Ref:

Strength

1=red

2=amber

3=green Date

Strength

1=red

2=amber

3=green

Internal /

External

C1 2 Feb-18 2 Internal

C2 3 Apr-17 2 Internal

C3 3 Mar-17 2 Internal

Cross Ref: Delivery Date Owner Ref:

Objective 3 Improving Mental Health and Wellbeing

Residual Risk score

Risk after consideration of controls

Risk Tolerance

The level of risk the CCG will tolerate in line

with the risk appetite

Date Risk

Added:

Risk Lead

Senior Commissioning

Manager Mental Health and

Continuing Healthcare

ControlsSpecific tasks and measure implemented to mitigate the effect of the

pricipal risks.

AssurancesReports/information received that confirms controls listed are working effectively

Evidencewhat was received and where

was it presented

Risk:Pressure on mental health acute beds

If pressure/demand exceeds the current bed base

provided by our commissioned services then

The CCG may not be able to meet its obligation to

commission effectively to meet the health needs of

our residents in terms of

• safety – through delayed admission and risk of stay

on an excessively high occupancy ward

• Clinical effectiveness: care not based on health need

or poor continuity of care

• Poor patient experience.

This could also adversely affect the CCG’s reputation.

Risk Owner

Director of CommissioningInherent risk score

before we consider any mitigation

Additional beds are now available as part of a risk share agreement

with Camden and Islington Foundation Trust (CIFT)

STP work on overall capacity including development of St Anne's

A new women's PICU has been opened to improve acute pathway for Islington

patients. The acute pathway remains a focus for the STP Mental Health work

stream.

There have been no further 12 hour breaches in finding mental health acute

beds. Risk has therefore been downgraded from 12 to 9.

Quarterly reports to Quality &

performance committee

Readmission rates are

reported to Contract review

group

The National Crisis Concordat has led to a local action plan to

enhance admission avoidance capabilityRegular performance reports to committee.





group

Risk share arrangement includes monthly meeting with CIFT to

monitor bed occupancy, identify issues and solve problems

STP, through Healthy London Partnerships, created service specification for

mental health place of safety outside of A&E.

During March increased demand on acute beds, as well as reduced discharges

resulted in long delays in A&E and on wards for patients waiting admission.

Gold command at CIFT was put in place which has brought the situation back

under control but capacity remains high at 98-100%.





group

Actionsactions taken to directly improve the effectiveness of controls or assurances

received Type

Gaps In Control / AssuranceAread requiring improvement where we lack control or assurance

Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite.

Review Committee Strategy and Finance Committee Date 17/04/2018

Committee Feedback There had been no further 12 hour breaches in finding Mental Health acute beds. Risk was therefore downgraded from 12 to 9 in February 2018.

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RAF Ref:

4084 5 20 4 2 8

Control Ref:

Strength

1=red

2=amber

3=green

Date

Strength

1=red

2=amber

3=green Internal /

External

C1 3 May-17 2 Internal

C2 2fortnightly

meetings2 Internal

C3 2 weekly 2 Internal

C4 3 weekly 2 Internal

Weekly Friday staff newsletter email record of staff newletters issued.Weekly newsletters via email.

Updates on intranet

Joint Haringey and Islington Executive Management Team meetings

weekly

Schedule of meetings and papers distributed to members and actions resulting

from meetings ciruclated to key officers.Minutes of previous meetings

Objective 4 Delivery of High Quality, Efficient Services Within Available Resources


principal risks.


Evidencewhat was received and where was

it presented

Date Risk

Added:

Risk:

NCL Commissioning Arrangements & Local Change

Process

Uncertainty over the NCL commissioning arrangements

and change process involving Haringey CCG, may occur

as a result of a lack of clarity and tranparency over the

organisation structure and impact on individuals and

teams. This could lead to loss of organsiational

knowledge from increased staff absenteeism/leaving

and also the over reliance on interim staff due to higher

levels of vacancies.

Risk Owner

Chief Operating Officer

Inherent risk score


Residual Risk score


Risk Tolerance



Risk Lead

Director of Commissioning

Appointments to key posts across NCL and the CCGNCL and COO now in post and attending key committees.

Turnover of staff during the past 3 months (20%)

CCG meeting records of

attendance

Fortnightly briefings to staff

Updates and presentations from Chief Officer and key individuals on programmes

of work. Wellbeing partnership, I Hub learning disabilities etc. Meetings moved to

Thursdays to improve attendance. Regular updates on structure changes and

plans.

Staff feedback at fortnightly briefings on issues concerning the changes

Schedule of staff briefings

planned ansd delivered.

Record of staff feedback at

group session Feb 2017

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C5 2 Sep-17 2 Internal

C6 3 N/A 2 Internal

C7 2 2 Internal

C8 2 2 Internal

C9 2 Sep-17 2 Internal



Committee Feedback This risk went through a review in February and since then there has been no change since last review.


record of meeting held.

New Joint Management Operating Model for Haringey and Islington

CCGs on 22/9/17. Period of engagement and 'Go Live' date 16th

October.

Details of period of engagement and the new perating model are available to staff

through the intranet.

Friday News provides link to

documents.

All new EMT directors appointed and in post bar Programme Director

for Care Closer to Home who starts on 16/10/17Directors in post and starting to attend meetings. N/A


received Type


OD programme being taken forward that includes mixed staff groups

doing task and finish work on flexible and SMART working in response

to the staff survey.

Haringey and Islington CCGs all staff away day booked for 30th

October - mixed group of staff to help co-design programme for the

day.

Away day joint working group met for its first meeting on Monday 25th

September

Pro-active recruitment to vacancies previously filled with interims to

give stability and promote continuity.

Number of new starters have commenced recently increasing the compliment of

permanent recruits in post.

Introductions at staff briefing

sessions

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RAF Ref:

4195 4 20 4 3 12

Control Ref:

Strength

1=red

2=amber

3=green

Date

Strength

1=red

2=amber

3=green

Internal /

External

C1 2 2 Internal

C2 2 monthly 3 Internal




Risk Tolerance



18/04/2018

Committee Feedback Draft dashboard has been developed and agreed by CCGs and Trust. For presentation to CCG committees in April & May 2018.



received Type


None identified None identified

Risk Lead

Assistant Director of Nursing

4.During 2017/18 the CQRG workplan will require the Trust to present focussed

items on community services.CQRG minutes and papers

3.The CCG uses contractural levers where quality and performce fails

below the standard required.3.Minutes from Contract Review Meetings and Contract Query Notices Meeting minutes and papers


pricipal risks.



it presented

1. Community disagregation to understand capacity and demand has

started with focus on specific services with long waits. ie how much

each service costs / is invested in.

1.Minutes of the meetings for each of the community disagregation workstreams

Copies of Minutes

2.The CCG ensures the Trust provides the minimum data to provide

assurance that services remain safe and issues relating to the quality

of services are being addressed.

2. CQRG papers and minutes demonstrate review and discussion of key quality

and safety metrics relating to the community contract.CQRG minutes and papers

Review Committee Quality and Performance Committee Date

Date Risk

Added:

Risk: Whittington Health - Quality of Community Service

Provision

There are a number of community services which are

performing poorly against current contract

specifications relating to access.This increases the

likelihood of harm, discomfort and poor quality

outcomes as a result of the longer waits.

Risk Owner

Director of Quality

Inherent risk score


Residual Risk score


4. CQRG will recieve assurance that quality of care is being protected

in services where access is underperforming.

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RAF Ref:

4205 4 20 4 3 12

Control Ref:

Strength

1=red

2=amber

3=green

Date

Strength

1=red

2=amber

3=green

Internal /

External

C1 2 Monthly 3 Internal



Risk Conclusion Risk currently being managed within agreed tolerance levels

Review Committee Quality and Performance Committee Date 18/04/2018

Committee Feedback There was no further update since last review.

Actionsactions taken to directly improve the effectiveness of controls or assurances Type



2. The CCG is assured that the Trust is resolving the SLA contract

issues identified by the CQC.2.Minutes of CQRG and Trust Board minutes will show resolution of SLA issues CQRG minutes and papers

1. The CCG has reviewed the Trust improvement plan addressing

every" Must do" and "Should do action" and there will be a robust

mechanism in place to review implementation1a. CQRG minutes will demonstrate that the CCG is provided with near time

updates on the progress made by the Trust in delivering improvements.

1b. The CCG will undertake insight visits to key services requring "Must do

actions" where assurance given at CQRG requires follow up.

1c.Reports on friends and family test, patient experience, complaints and SI's.

Copies of CQRG Minutes

Insight visit action plans to

CQRG meetings

F&F Test, SI, Complaints

Reports to CQRG and Q&P

committee (minutes and

papers)

Inherent risk score


Residual Risk score


Risk Tolerance



Risk Lead


Date Risk

Added:

Risk: Moorfields - standardisation of service provision

The lack of formally agreed service level (SLA) contracts

acorss satelitte sites potentailly leads to poor service

provision resulting from ineffective quality governance

systems. This inturn restricts the drive for

improvement, standardising of practices and

influencing of change which can lead to poor patient

outcome and experience.

Risk Owner

Director of Quality


pricipal risks.



it presented

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RAF Ref:

4215 5 25 4 3 12

Control Ref:

Strength

1=red

2=amber

3=green

Date

Strength

1=red

2=amber

3=green

Internal /

External

C1 2

1a Monthly

1b Periodically3 Internal



C1 Jan-18 Director of Quality


received Type


2. Monthly Internal audits by Trust quality leads taking place 2. Results from monthly audits demonstrate positive progress to date.Audit Reports

Date Risk

Added:

Risk: Moorfields - Safer Surgery checlkist

The failure to utilise the WHO safer surgery checklist

may lead to inconsistent practices across sites which in

turn increases the chances of never events occuring and

patients being exposed to harm or clinical incidents..

Risk Owner

Director of Quality


pricipal risks.



it presented

1. There are CQC "Must do" actions relating to the WHO checklist

.Action plan in place

1a. CQRG minutes demonstrate close oversight of the "Must do " actions including

the WHO checklist.

1b.The outcome of audits demonstrating compliance with WHO checklist is

presented at CQRG.

1a CQRG minutes and papers

1b Audit reports to CQRG

Inherent risk score


Similar visit to the one at City Road Theatres is planned for the St

Georges site.assurance



Committee Feedback The current controls and planned controls continue. The visit planned to St Georges has not yet taken place. Risk rating remains the same.

Residual Risk score


Risk Tolerance



Risk Lead


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RAF Ref:

4225 4 20 4 3 12

Control Ref:

Strength

1=red

2=amber

3=green

Date

Strength

1=red

2=amber

3=green

Internal /

External









pricipal risks.



it presented

1. The CCG holds the Trust to account for adhering to the national

guidance on the management of serious incidents (SIs)

1&3.CQRG minutes will demonstrate close oversight of the Trust's adherence to

the national guidance. Copies of CQRG Minutes

2.The Trust is conducting 72 hour reviews of all serious incidents

2. Minutes of the NCL SI panel will provide assurance that 72 hour reports become

business as usual in the management of SIs . The Interim Director of Quality will

request sight of 72 hour reports

NCL SI Panel minutes and

papers

3. There is appropriate scrutiny of SIs reported by the Trust

CQRG minutes will demonstrate that quarterly SI assurance reports generated for

the CCG by the CSU are presented, discussed and appropriate actions agreed with

the Trust.

Currently no assurance on the Trust's compliance with part 2 Duty of Candour

requirements.

CQRG minutes and papers

Inherent risk score



Committee Feedback The risk is to be reviewed following May's CQRG.


Residual Risk score


Risk Tolerance



Risk Lead


Date Risk

Added:

Risk: Moorfields - SI system adherence

A lack of adherence to the 2015/16 serious incident

framework and failure to provide evidence over the

completion of part 2 Duty of Candour, will lead to poor

learning from incidents and an increased likelihood of

repeat occurrences. The likely result is a detrimental

impact on the reputation of the CCG through a lack of

feedback around meeting Duty of Candour and an

increase in poor patient outcomes.

Risk Owner

Director of Quality

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RAF Ref:

4234 5 20 4 3 12

Control Ref:

Strength

1=red

2=amber

3=green

Date

Strength

1=red

2=amber

3=green

Internal /

External





Jan-18 Director of Quality

Committee Feedback Reviewed risk in April. Updated assurance and mitigations.

External review of service

2 stakeholder assurance meetings held. Evidence has been received but not yet

full assurance.

External report

Date Risk

Added:

30/6/17

Risk: Whittington Health - LUTS

The Trust and Commissioners have agreed a phased

reopening of the LUTs clinic as a tertiary service for

adult patients subject to conditions set out by the NCL

Joint CCG Commissioning Committee in April 2018.

There is a risk that the agreed specifcation for 2018/19

may not be met.

Risk Owner

Director of Quality


pricipal risks.



it presented

1. The Trust is not accepting new patients in to the service until the

RCP recommendations have been fully implemented.

The NCL Director of Commissioning and CCG Director of Quality are in attendance

at paitent group meetings.

Patient Group meeting minutes

Inherent risk score


Residual Risk score


Risk Tolerance





received Type


Desk top review being undertaken None identified

2. The NCL Director of Commissioning and the CCG Director of Quality

are attending meetings with the Trust Deputy Chief Executive to

monitor delivery of the action plan including the succession plan and

work towards the service being delivered within a teriary setting

Notes of patient group meetings provided to the Chieft Operating Officer and

Accountable Officer.Patient Group meeting minutes

3.CCG Director of Quality and Head of Medicines Management attend

the MDT meetings to be assured of the safety of the service..

Risk Lead


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RAF Ref:

4254 4 16 4 3 12

Control Ref:

Strength

1=red

2=amber

3=green

Date

Strength

1=red

2=amber

3=green

Internal /

External

C1 2 bi monthly 2 Internal

C2 2 3 Internal

C3 2 2 Internal

C4 2 2 Internal

C5 3 3 Internal


C1

Committee Feedback No change since last review.


None identified as yet. None identified

Review Committee Patient and Public Participation Committee Date 18/04/2017

The corporate services review is proposing to move communications

and engagement under the performance and delivery directorate.Copy of Agreement with the

council


received Type


CCG Engagement Lead feeds in to the STP on what engagement

should look like. Wellbeing Partnership

meetings

Joint Engagement and Communications working Group for the STP. Joint engagement and communication meeting papers and minutes although

current concerns exist over the gravitas of the groups which are often poorly

attended.

Joint meeting papers and

minutes

Patient Voice delivers a broad reach Regular updates feed in to the Patient and Public Participation Committee PPP Meeting minutes bi-

monthly

Developed engagement approach for Wellbeing Partnership which

has been signed up to and also engagement approach for STP. Signed engagement agreement

Residual Risk score


Risk Tolerance


Risk Lead



pricipal risks.



it presented

Date Risk

Added:

17/8/17

Risk: STP engagement

The STP covers a wider footprint with an increased

number of partners. This could lead to engagement

becoming less effective, with groups that experience

high levels of deprivation and inequalities potentially

not being heard. This could jeopodise the relationship

with the community and cause significant reputational

damage for the CCG.

Risk Owner

Director of Quality

Inherent risk score


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RAF Ref:

4265 5 25 4 3 12

Control Ref:

Strength

1=red

2=amber

3=green

Date

Strength

1=red

2=amber

3=green

Internal /

External

C1 2monthly

2 Internal


C1




received Type




Residual Risk score


Risk Tolerance


Risk Lead



pricipal risks.



it presented

Stakeholder meeting to be held involving Islington CCG, Camden CCG,

NHSE, C&I FT to review in detail evidence to support the

impementation of agreed actions.

Output from the stakeholder evidence review meeting fed in to the January and

February CQRG meetings will provide assurances over the current level of

implementation of actions.

Evidence trail.

CQRG minutes and papers

Date Risk

Added:

31/01/18

Risk: Camden & Islington FT - Mr G external investigation

oucome

Failure to deliver recommendations within the action

plan, increases the likelihood of similar incidents

occuring, potentially leading to further harm to

patients or members of the public.

NHSE commissioned an independent investigation in to

the organisations management of a service user who

committed homicide whilst under the care of the Trust.

Risk Owner

Director of Quality

Inherent risk score


142 of 186



RAF Ref:

4274 3 12 4 3 12

Control Ref:

Strength

1=red

2=amber

3=green

Date

Strength

1=red

2=amber

3=green

Internal /

External

C1 2 2 Internal

C2 1 1 Internal


C1


Trust is currently doing checks against names to confirm that all are

being managed correctly. Discussions taking place with LA around

improving the linkage between the two systems. Report is due back to

the CQRG (date to be confirmed).

Internal review of names being completed to check no one falling through the gap.

This will likely result in an improvement action plan.

Improvement plan





pricipal risks.



it presented

The Local Authority and Trust to meet and look at a way forward and

to look at the drive.

Meeting to take place

Minutes



Date Risk

Added:

31/01/18

Risk: Islington (Borough Council and NHS Trust) and

Camden and Islington FT Adult Safeguarding Process

The electronic drive is held by the Local Authority

(London Borough of Islington) and shared with the Trust

(Camden and Islington NHS Foundation Trust). In

November 2017, it became apparent that the drive

contains lists of names, including safeguarding

concerns, police referrals etc and the Trust were not

accessing the list and were not aware of the list. There

is no electronic link between the LA and Trust system

for safeguaridng adults. This could result in patients

falling through the system unmanged, increasing the

chances of safeguarding concerns materialising.

Risk Owner

Director of Quality

Inherent risk score


Residual Risk score


Risk Tolerance


Risk Lead


143 of 186

4.1.1 RAF Format ICCB GB April 2018


RAF Ref:

409 5 4 20 3 4 12

Control

Ref:

Strength

1=red

2=amber

3=green Date

Strength

1=red

2=amber

3=greenInternal /

External

C1 2Monthly

2

Internal

C2 2Monthly

2Internal

C3 2 Fortnightly 2

Internal

C4 2 Fortnightly 2

Internal

C5 2 Fortnightly 2

Internal

C6 2 Fortnightly 2

Internal

Other Statutory Obligations and Core Business

ControlsSpecific tasks and measure implemented to mitigate the effect of the pricipal

risks.



it presented

Date Risk

Added:

26/6/2017

Risk: 2017/18 QIPP Programme Delivery

The QIPP target is set at £11.749m, £5.2m of which is

expected to be delivered through the STP. The STP QIPP

programme is largely transformation which requires

substantial changes to models of care.

Any slippage in QIPP (or unidentified QIPP) will need an

action plan in plan to recover the position and mitigate

financial and performance risks to the organisation. Failure

to achieve the CCG QIPP plan is likely to impact on the

organisation's ability to meet its financial control total for the

year and, as a result, the NCL Financial Control Total.

Risk Owner



Inherent risk score


Residual Risk score


Risk Tolerance

The level of risk the CCG will tolerate in

line with the risk appetite

Risk Lead

Acute Contracts & QIPP

Consultant

A monthly dashboard highlighting current and FOT QIPP achievement

against planned outcomes.

Monthly QIPP Reports to Exec Management Group, Strategy and Finance, &

Governing Body

Month 8 reports show slippage of £2.9m against forecastQIPP reports

Senior management and clinical leads for each QIPP schemes. Monthly QIPP Reports to Exec Management Group, Strategy and Finance, &

Governing Body QIPP reports

The frequency of the QIPP delivery group has been increased to

fortnightly to drive the pace of change and ensure any barriers are

escalated to EMT members for resolution.

STP/CSU reporting performance against STP QIPP

STP reports to CCG

Fortnightly meetings are in place with providers to drive change (i.e.

local delivery team meetings)


Provider report

QIPP reports

QIPP reports

Financial and Activity reporting on STP QIPP via CSU and STP PMO

Finance Budget Monitoring Meetings for Non-STP QIPP monitoring

Providers report


144 of 186



Date Risk

Added:

26/6/2017












Risk Owner



Inherent risk score


Residual Risk score


Risk Tolerance


line with the risk appetiteCross Ref: Delivery Date Owner Ref:

C1

Committee Feedback This risk is recommended for closure as the new 2018/19 QIPP Risk has been opened - Risk ID 437.


Actions

actions taken to directly improve the effectiveness of controls or assurances

received Type

Gaps In Control / Assurance

Aread requiring improvement where we lack control or assurance

No further actions agreed.


145 of 186



Date Risk

Added:

26/6/2017












Risk Owner



Inherent risk score


Residual Risk score


Risk Tolerance




RAF Ref:

428 4 5 20 4 3 12

Control

Ref:

Strength

1=red

2=amber

3=green Date

Strength

1=red

2=amber

3=greenInternal /

External



C3 2 2 Internal

Residual Risk score


Risk Tolerance



Risk Lead

Head of Medicines

Management


risks.



it presented

Date Risk

Added:

20/10/2017

Risk: Medicines management

A significant national increase in the number of short supply

high volume generic medicines (categorised as No Cheaper

Stock Obtainable, NCSO in the Drug Tariff) has created an

unpredictable rise month on month in the cost of these

items. As a result, the CCG has predicted a potential

additional overspend for these medicines in excess of

£1.4m.

This is a national issue being managed by NHS England and

the Department of Health. NHS England has published the

guidance ''Refreshing NHS plans for 2018/19", which makes

it clear that CCGs should assume that the high level of

discretionary prices for generic drugs in short supply will not

persist in 2018/19.

Risk Owner

Director of Planning and

Delivery

Inherent risk score


The London Pharmacy leads meet regularly to consider options in

respect of this issue and have escalated the issue to Department of

Health and NHS England.

There has been some positive movement in respect of Olanzapine coming off

the list although there are a significant number of other drugs currnetly being

reviewed for inclusion on the NCSO list.

Report to S&F Committee

December 2017

The Pharmaceutical Services Negotiating Committee have made strong

representations to the Department of Health regarding the potential

impact for patients and community pharmacies of continuing shortages.

http://psnc.org.uk/our-news/update-generics-supply-

situation/?utm_source=PSNC+Newsletter&utm_campaign=0f5496bc48-

EMAIL_CAMPAIGN_2017_09_25&utm_medium=email&utm_term=0_b5

ca69e1d1-0f5496bc48-48575589

The financial impact of the lack fo supply is estimated to fall between £1.3m

and £1.8m. However this cannot be predicted with any certainty due to the

possibility of additional medicines being added to the shortage list or of

medicines coming back into supply and the risk reducing.

Report to S&F Committee

December 2017

Refreshing NHS plans for 2018/19' guidance has made it clear that CCGs

should assume that the high level of discretionary prices for generic

drugs in short supply will not persist in 2018/19.

CCGs should assume that the current high level of discretionary prices for

generic drugs in short supply will not persist in 2018/19. In 2018/19, CCGs will

receive the remaining period of temporary benefit from changes made to

Category M generic drug prices designed to recover excess community

pharmacy margin from previous years (i.e. the Cat M clawback will not

continue beyond 2017/18).

https://www.england.nh

s.uk/wp-

content/uploads/2018/0

2/planning-guidance-18-

19.pdf

146 of 186

https://www.england.nhs.uk/wp-content/uploads/2018/02/planning-guidance-18-19.pdf







Date Risk

Added:

26/6/2017












Risk Owner



Inherent risk score


Residual Risk score


Risk Tolerance


line with the risk appetiteCross Ref:

Delivery

Date Owner Ref:


RAF Ref:

108 4 3 12 4 3 12

Control

Ref:

Strength

1=red

2=amber

3=green Date

Strength

1=red

2=amber

3=green

Internal /

External



The education programme for GPs, practice nurses and practice staff

The primary care team is now fully established

Development funding in primary care strategy for practice managers,

practice nurse and practice-based pharmacists

Creation of blended roles for urgent care developed through CEPN

Primary Care monires used to establish practice based pharmacists and

potential for physiotherapists too subject to NHSE release of investment

monies.

Existing Assurance

CCG Workforce working group reviews the workforce development aspects of

the primary care strategy

Planned Mitigation

A programme for practice nurses to enhance deliver of the '6 C' strategy

is being scoped. Existing Assurance

CCG Workforce working group reviews the workforce development aspects of

the primary care strategy

Residual Risk score


Risk Tolerance



Risk Lead

Assistant Director of Primary

Care Commissioning


risks.



it presented

Date Risk

Added:

20/10/2017

Risk: Primary care workforce development

If the CCG is ineffective in developing the primary care

workforce then this may have an adverse impact on the

delivery of the primary care strategy

This could mean that for example, patients with long term

conditions are not fully supported in primary care and

require more frequent hospital care.

Risk Owner

Director of CommissioningInherent risk score


Actionsactions taken to directly improve the effectiveness of controls or assurances received Type


Committee Feedback The recommendation is to reduce that risk rating from 16 to 12 given that recent reporting has shown a decline in the financial impact of NCSOs.


No further actions agreed.


147 of 186



Date Risk

Added:

26/6/2017












Risk Owner



Inherent risk score


Residual Risk score


Risk Tolerance



C3 2 2 Internal

Cross Ref:

Delivery

Date Owner Ref:

Risk Conclusion

Committee Feedback This was in the process of being reviewed in February and since then there has been no change since last review.


Gaps in Mitigation

The CCG could consider the global recruitment of practice nurses funded

in part through the strategy fund but this would require joint working

and consultation with the LMC and practices.

Opportunity to build resilience in primary care through the uplift in

funding for primary medical services in 2016/17 and 2017/18



148 of 186



Date Risk

Added:

26/6/2017












Risk Owner



Inherent risk score


Residual Risk score


Risk Tolerance




RAF Ref:

434 5 3 15 4 3 12

Control

Ref:

Strength

1=red

2=amber

3=green Date

Strength

1=red

2=amber

3=green

Internal /

External



C3 2 2 Internal

Cross Ref:

Delivery

Date Owner Ref:

Committee Feedback In progress for review






risks.



it presented

Planned Controls

- liaising with Camden and Islington OSCs to ensure consultaiton

documentation and methodology is approved before going to

consultation

-Working on service models with CIFT

- NHSE London Clinical Senate reviewing PCBC, consultaiton documents

and clinical case for change on 15th May, which is part of the NHSE

assurance programme

- Ensuring robust project planning

- Obtaining legal advice to ensure that PCBC and consultation

documents are fit for purpose

- Commissioned advice from the OCnsulation Institute to ensure best

practice on methodology and process

St Pancras Fortnightly Steering group. David Mallet is attending.

In progress for review

Date Risk

Added:

31/01/2018

Risk:Re-development of St Pancras site

Delayed start of consultation, failure to gain assurance from

NHSE on process, threat of judicial review, not enough

capacity to carry out a more thorough public consultation

and currently no support from Clinical Senate for clinical

proposals, means the whole re-development of the St

Pancras site is at risk.

Risk Owner

Chief Operating Officer

Inherent risk score


Residual Risk score


Risk Tolerance


Risk Lead

Associate Director of Joint

Commissioning

149 of 186



Date Risk

Added:

26/6/2017












Risk Owner



Inherent risk score


Residual Risk score


Risk Tolerance




RAF Ref:

437 5 4 20 5 3 15

Control

Ref:

Strength

1=red

2=amber

3=green Date

Strength

1=red

2=amber

3=greenInternal /

External

Residual Risk score


Risk Tolerance



Risk Lead

Acute Contracts & QIPP

Consultant


risks.



it presented

Date Risk

Added:

17/04/18

Risk:

2018/19 QIPP Programme Delivery

The QIPP target is set at £12.6m net savings. The QIPP

programme is largely transformational which requires

substantial changes to models of care. Agreement as to the

level of QIPP contained within provider contracts as part of

STP initiatives has not concluded in March 2018 and the

contract with Whittington Health is subject to mediation. The

outcome of mediation is that Clinical Review sessions are

taking place between commissioners and providers to be

concluded by 30/4/18. Contractual agreement regarding

levels of QIPP within provider contracts is one of the key

mechanisms to delivering QIPP savings.

Risk Owner


Performance and Delivery Inherent risk score


150 of 186



Date Risk

Added:

26/6/2017












Risk Owner



Inherent risk score


Residual Risk score


Risk Tolerance





C3 2 2 Internal

Cross Ref:

Delivery

Date Owner Ref:



Current controls

- Clinical review meetings are taking place with Whittington Health to

agree the extent of QIPP which is included in the 2018/19 provider

contract. These are being jointly led by the QIPP lead for Islington CCG,

the Clinical Chair of Islington CCG and the Director of Planning,

Performance and Primary Care for NCL CCGs and the process will be

concluded by 30/4/18.

- A monthly dashboard highlighting current and FOT QIPP achievement

against planned outcomes is in place.

- Senior management and clinical leads are in place for each QIPP team.

- The frequency of the QIPP delivery group is continuing fortnightly to

drive the pace of change and ensure senior directors and Governing

Body members are able to support the unblocking of any barriers. The

focus of the group is on ensuring large transformational schemes are

delivered on time.

- Financial and Activity reporting on STP QIPP is in place via the CSU and

STP PMO to a consistent standard across CCGs.

- Finance Budget Monitoring Meetings for Non-STP QIPP monitoring are

in place.

- Lessons learned from 17/18 and the NHSE QIPP Review (February

2018) have been incorporated into 2018/19 delivery planning and the

programme is much more evenly phased than 2017/18.

Planned controls

- There is continued Pan NCL collaborative working to identify further

opportunities and standardise pathway changes to best ensure the

engagement of providers across NCL

Weekly QIPP Reports to Exec Management group

Monthly QIPP Reports to Strategy and Finance, S29& Governing Body


Monthly Financial performance reporting

Haringey and Islington Joint QIPP delivery group meets on a fortnightly basis.

In progress for review

Committee Feedback New Risk. Risk was discussed at the Strategy & Finance on 26 April 2018.



151 of 186

Q2 Q3 Q4 Q1 Q2 Q3 Q4

Delivery of High Quality, Efficient Services Within Available Resources


Oversight of quality and safety issues

An undetected and unaddressed failure in a commissioned service due to poor performance or quality of services could result in

• poor patient experience

• potential patient harm

• missed targets

Resulting in

• Failure to meet our statutory and strategic obligations

• Damage to CCG’s reputation

The CCG is the lead commissioner for the Whittington, Moorfields, Camden and Islington Foundation Trust (for mental health), Care UK GP out of hours services, and the local NHS 111

service.

15 8 8 8 8This risk is now superseeded by

additional rquality risks added.


Workforce and succession planning

If the CCG does not effectively recruit, retain or plan for succession for its workforce it may not deliver on its local leadership role, key projects, overall strategy and statutory

obligations

15 8 8 8 8This risks has been superseeded

by risk 408

410 Quality & PerformanceThe failure to deliver community services in line with historical investment and the specifications agreed within the Community Services Contract leads to concerns over the quality and

timeliness of services being escalated and formal contract notices being issued.16 12 12 12

This risk has been superseeded

by risk 42


Impact of Extended Access Services

ICCG has recently contracted for Extended Access services as a 2+1 year contract that commenced in April 2017.

The STP plan indicates a substantial reduction of A&E attendances as a result of the succesful implementation of this service. The risk is that this expected impact is not delivered. As

this is a relatively recently developed service, the national evidence around the expected impact on A&E attendances is limited, and locally we have not been able to identify a clear

impact from the pilot to date.

16 12 12 12Now covered as part of STP

management

406 Strategy & FinanceThere are operational and financial risks relating to continuing health care occuring from the backlog of follow up assessments. This excludes the national rate increase for funded

nursing care which is now closed. The new 2018/19 AQP is being drawn upand the new contracts should promote innovation and quality.15 25 6 6 6

The risk has been fully mitigated

and is unlikely to reoccur.


Implementation of Integrated Digital Care Record

If the CCG does not manage the implementation stage of this programme effectively, then there may be cost overrun, late delivery, poor functionality or a failure to realise the intended

benefits of the programme.

Potential adverse consequences include

• Inability to introduce new care models

• Poor return on investment

• Commissioning and contract delivery impeded

• Inability to benchmark CCG

• Knock-on effect on other projects

• Development of clinical pathways affected

• Patient & public engagement affected

• Damage to CCG reputation and relations with stakeholders

12 20

The IDCR project has now closed

and will be replaced by an NCL

wide HIE.


Camden and Islington FT - CQC Compliance

The failure to deliver month on month service improvements in the areas specified by the CQC following a "requires improvement" rating could lead to a deterioration in the quality of

care delivered and poor patient experience.

20 9 9 9 9

It has been stable all year and

therefore has been removed

from the RAF


Camden & Islington FT - Mr T external investigation outcome

Failure to deliver recommendations within the action plan, increases the likelihood of similar incidents occuring, potentially leading to further harm to patients or members of the

public.

25 20 12

At Quality & Performance

Committee on 13/02/18, it was

felt that this is no longer a risk

and the Committee agreed to

close and remove this risk.

GOVERNING BODY RISK ASSURANCE FRAMEWORK

RISKS REMOVED FROM THE RAF DURING 2017/18

Risk Ref

Review


Inherent Risk

Score

2016/17

Reasons for removal

Objective 3

Risk Movement

since last Qtr

17/18

152 of 186

North Central London CCG Risk Register as at April 2018 App 4.1.2

ID Director Objective Risk Controls in place Evidence of Controls

Overall Strength of Controls in

Place

Consequence Likelihood (Current)

Rating (Current)

Risk level (Current)

Controls Needed Evidence of Controls Needed Actions Action Completion Date Update on ActionsConsequence

Likelihood (Target)

Rating (Target)

Risk level (Target)

A1. 30.09.2017A2. 01.07.2018A3. 23.03.2018

3 12

High

CN1. CCG system leadership for commissioning. Contract requirement to signal major contact/service changesCN2. Proposals for realigning system incentives.

A1. Develop and sign-off system intentions for 2018/19A2. Develop, in co-production, with providers, proposals for alternative contract forms for hospital providersA3. Development of planning assumptions for 2018/19 with providers.

A1. Action completed. System intentions issued to providers. A2. Consideration of models used elsewhere - Aligned Incentive Contract in Bolton; Accountable Care models. Work has commenced on this and is continuing.A3. Planning assumptions are being developed through STP finance meetings following publication of national planning guidance. 4

4 3 12

High

JCC11

Paul Sinden, NCL Director of Performance and Acute Commissioning

Management of acute contracts to ensure contracts are delivered within contact baselines (CCG resource envelopes)

Managing acute contracts within contract baselines (Threat)

Cause: if expenditure on acute contracts exceeds planned contract baselines

Effect: There is a risk that CCGs will not meet their financial duties and/or investment is withheld to support delivery of the Sustainability and Transformation Plan

Impact: This may result in delays to investing in primary care and community capacity and perpetuate the risk over performance on acute hospital contracts

C1. Signed contracts in place for 2017/18 and 2018/19C2. Contracts include marginal rate payments/deductions for variances from plan and 3% growth (higher than historic growth trends) C3. Contract management framework in place with providersC4. Issue of contract notices in line with contact provisionsC5.. Mobilisation of STP and QIPP plans (see JCC10)C6. North Central London Finance and Activity Modelling (FAM) Group, with commissioner and provider membership. that oversees system financial positionC7. Work on alternative contract forms to support the Sustainability and Transformation Plan (STP) through the Acute Contract Modelling Group (with commissioner and provider membership)C8. Quarter one reconciliation agreed with providers as a precursor to establishing the opening contract baseline for 2018/19C9. Agreement of treatment of disputed items with Royal Free London in 2017/18 reached

C1. Signed contractsC2. Signed contractsC3. Meeting minutes and papersC4. Contract documentation and correspondence including remedial action plansC5. See JCC10C6. Meeting minutes and papersC7. Meeting minutes and papersC8. Meeting minutes and papers

Average

4 4 16

Very high

CN1. Development of system intentions for 2018/19CN2. Develop proposals to realign system incentives including new contract forms for hospital contracts


JCC 10

CN1. Realigned CCG and CSU teams for contract frameworks that release resources to support the STPCN2. Proposals for alternative contract form

Very High

3 4 12

High

RISKS FROM THE NCL JOINT COMMISSIONING COMMITTEE

Very High

CN1. Arrangement to be put into place to ensure all providers are abiding by the inter-provider transfer protocol.CN2. Individual providers to resolve internal pathway issues to ensure they meet the 62 day target.CN3. Backlog reduction by providers to level consistent with delivery of the waiting time standard.

CN1. Improvements delivered in-line with agreed trajectories and contained in reports.CN2. Improvements delivered in-line with agreed trajectories and contained in reports.CN3. Analysis agreed with NHS Improvement indicates maximum backlog level to deliver the standard

A1. Continue to work with providers on delivering the trajectories.A2. Continue to work with providers to ensure sustainable delivery and includes work through the cancer vanguard.A3. NCL recovery of the 62 day standard by December 2017.A4. UCLH recovery of the 62 day standard by end of March 2018 and is consistent with system recovery by December 2017. Updated recovery plan required from the Trust.

A1. Provider meetings continue on a fortnightly basis on recovering the trajectories. A2. Cancer vanguard meetings in place with provider and commissioner representation which meet monthly.A3. NCL delivered the standard in December 2017 but further work is required for sustainability. This work is being undertaken and is reflected in action A4.A4. UCLH recovery plan received but defers recovery to June 2018 from expected recovery by March 2018. Internal pathways are expected to be compliant by April 2018.

A1. 30.06.2018A2. 30.06.2018A3. 30.06.2018A4. 30.06.2018

C1. Meeting papers and notes.C2. Plans and trajectories in place with providers to allow NCL to meet the standard overall. Backlog analysis indicates reduction towards sustainable level. Progress most marked at Royal Free London in October and November. C3. Plans. C4. Transfer protocol document.C5. Provider trajectoriesC6. Provider recovery plan

Average

4 4 16JCC 1


62 Days Waiting Time Standard is Met

Delivery of Cancer 62-day waiting time standard (Threat)

Cause: There may be insufficient capacity within the system, and inefficiencies along pathways in particular for inter-provider transfers.

Effect: There is a risk that the system may be unable to cope with the level of demand and has limited resilience to unexpected events.

Impact: This may result in people not receiving treatment within 62 days with potential adverse impact on their health outcome.

C1. North Central London ('NCL') cancer governance arrangements established to cover both performance and transformation.C2. Improvement trajectory agreed with NHS England and NHS Improvement.C3. Remedial Action Plans in place with providers that are not meeting the 62 day standard. Updated plan received from Royal Free London.C4. 38 day transfer protocol in place for inter-provider transfers from district general hospitals to tertiary services with the 38 day standard compatible with treatment commencing within 62 days.C5. Trajectory agreed with providers to meet the 38-day standard for transfers of careC6. Recovery plan received from UCLH, with overall compliance by June 2018 and compliance on internal pathways by April 2018

16

Average

44

Mobilisation of STP and QIPP plans (Threat)

Cause: if we do not ensure that STP and QIPP plans are delivered in accordance with planning assumptions

Effect: There is a risk that contracts will not be delivered within resource envelopes for 2017/18

Impact: This may result in delays to service changes, higher contract baselines for 2018/19 than anticipated in financial plans for CCGs, and a wider system financial gap.

CN1. CCG and CSU redirection of capacity to support mobilisation of STP interventionsCN2. Collaborative work with providers to realign system incentives, and contract form, to support STP delivery

Effective mobilisation of Sustainability and Transformation (STP) plans and CCG QIPP plans to ensure contracts remain within resource envelopes

A1. Finalise proposals to increase support for STP work streams A2. Progress the work of the acute contract modelling group to consider alternative contract forms

A1. In-housing of NELCSU to provide greater support and capacity for delivery of STP interventions is underway.A2. Work is progressing but needs additional capacity to put into place shadow proposals for 2018-19.

C1. Signed contractsC2. Meeting minutes and papersC3. Signed contractsC4. Meeting minutes and papersC5. Meeting papersC6. Meeting papers and project initiation documents

C1. Signed contracts in place for 2017/18 and 2018/19C2. Contract frameworks in place with each provider including Local Delivery Teams to support the STPC3. In-year contract variances subject to marginal rates rather than full tariff adjustments C4. Collaborative arrangements in place through Finance and Activity Modelling (FAM) Group as part of STP governance frameworkC5. Sustainability and Transformation Plan governance and supporting work streams with commissioner and provider membership in placeC6. Development of schemes for 2018/19 underway. Project initiation documents shared with providers for planned care, care closer to home, and urgent and emergency care

A1. 01.07.2018.A2. 01.07.2018

153 of 186



Place


Rating (Current)



Likelihood (Target)

Rating (Target)

Risk level (Target)

A1. 13.10.2017A2. 30.11.2017A3. 31.12.2017A4. 31.01.2018A5. 31.03.2018A6. 30.04.2018.

A1. 30.11.2017A2. 23.03.2018A3. 23.03.2018A4. 01.07.2018A5. 01.07.2018

A1. 31.01.2018A2. 31.03.2018A3. 23.03.2018A4. 31.01.2018

High

A1. Plans submitted to STP finance group in November 2017.A2. Options being refreshed following issue of national planning guidance.A3. Negotiations are underway with completion targeted in line with national timetable.A4. Work is progressing but needs additional capacity to put into place shadow proposals for 2018-19.A5. Open book approach to provider cost profiles agreed and work is underway to provide the information.

3 3 9

16

Very high

4 4 16

Very JCC 18

Paul Sinden, NCL Director of Performance

Reducing the system financial

NCL is a system in deficit. One of the aims of our Sustainability and Transformation Plan is to deliver financial recovery and maintain and sustainable health and care system. The STP sets out the challenges to financial recovery from demographic and demand trends. (Threat)

Cause: if our plans do not deliver financial balance

Effect: There is a risk that additional savings plans will need to be developed that have a greater impact on service delivery and access than current plans, and the local system comes under greater scrutiny from regulators.

C1. STP finance meeting established that has a common view of system deficit C2. Collaborative approach to contracting round for 2017/18 and 2018/19 C3. Work on alternative contract forms for future years to support cost reductionC4. Monthly reporting cycle and monitoringC5. Working groups established for areas of pressure and with scope for cost reduction - estates, continuing healthcare, demand management etc.C6. Iterative CCG QIPP plans

C1. Meeting papers and minutes from STP finance group C2. Contract documentation; notes from STP finance group.C3. Notes from acute contract modelling groupC4. ReportsC5. Meeting notesC6. Reports.

Average

4 5 20

Very CN1. Identify opportunities for year-end settlements with providers to allow planning certainty and focus on cost reductionCN2. Identification of further savings opportunities for the system CN3. Ensure mobilisation of STP and local interventions (see JCC 10)

CN1. Quarter one reconciliation process. Both CCGs and providers under financial pressure CN2. CCG finance reports - risks outweigh opportunities in 2017/18CN3. See JCC10

A1. Finalise quarter one reconciliation process to identify opportunities for year-end settlementsA2. Continue to identify further savings opportunities A3. 2081/19 planning round to set contract baselines for 2018/19A4. Greater alignment of CCG QIPP and provider cost improvement programmes (CIP) for 2018/19

A1. Action completed. A2. Work is on-going. Opportunities are being developed through STP finance group and locally by CCGs A3. Process for planning round agreed through STP finance group and work is on-going.A4. QIPP/CIP meeting held in January 2018.

JCC 14


Mobilising STP schemes that shifts activity away from acute providers in a way that allows those providers to release capacity and costs, and thereby reduce overall system costs

STP and local plans target the shift of care from hospital into community settings, to reduce the overall system financial deficit this needs to be done in a way that allows hospital providers to reduce capacity and costs. This risk follows on from the initial risk of mobilising STP and local plans in JCC10 (Threat)

Cause: if we are unable to shift care from hospital to community settings that allow providers to make a step-change in capacity

Effect: There is a risk that hospital providers are left with stranded costs and we do not reduce overall system costs

Impact: STP and local interventions do not help reduce the system financial deficit in the anticipated way.

C1. Signed contracts for 2017/18 and 2018/19 that include the impact of STP interventionsC2. System intentions for 2018/19 that seek to align intentions across CCGS so we commission at scaleC3. Agreement of approach to planning round for 2018/19 with providers through STP finance meetings. Contract baselines for 2018/19 to include the impact of STP interventions. C4. Work with providers on alternative contract forms to support STP delivery, with the work informed by provider cost profiles.C5. STP Finance meetings with commissioners and providers that has a common understanding of financial position in NCL systemC6. STP interventions for 2018/19 developed and shared with providers

C1. Contract documentationC2. NCL Systems Intentions letterC3. Meeting paper and notes.C4. Meeting papers and notes. C5. Meeting papers and notesC6. Meeting papers and project initiation documents.

Average

4 4 16

Very high

CN1. Development of STP work streams interventions plans for 2018/19CN2. Agreement of contract baselines for 208/19 CN3. Development of alternative contract models and incentive systems

CN1. Interventions impacts need to be planned and agreed for incorporation into contractsCN2. Signed contracts for 2017-19 require the negotiation of contact baselines for 2018/19CN3. Alternative contract forms need to be shadow run in 2018/19 to be used in contracts from 2019/20 onwards

A1. Work streams development of STP plans for 2018/19.A2. Agree option for setting contract baselines for 2018/19.A3. Negotiation of contract baselines for 2018/19 incorporating 2017/18 plan/outturn, growth and impact of interventions.A4. Agree models for alternative contract forms to be shadow run in 2018/19A5. Create finance and activity schedules that support the shadow running od the alternative contract forms.

A1. Agree escalation process for NCL with NHS England and NHS Improvement A2. Hold winter workshop on 27 SeptemberA3. Identification of further recover plans through winter workshop and A&E Delivery BoardsA4. Provider mutual aid plans developed for January 2018 to free up clinical time from elective care pathways to support emergency patient flows A5. Each A&E deliver board to complete an after action review process for winter 2017-18.A6. Plans for winter 2018-19 to be submitted to NHS England by end of April 2018.

A1. Action completed. NCL approach to escalation agreed in principle with NHS England. All A&E Delivery Boards have agreed escalation protocols to respond to surges in pressure and/or demand A2. Action completed. Actions from winter workshop were actioned through A&E Delivery Boards A3. Additional plans submitted by A&E deliver boards in December 2017.A4. Action completed. A5. Work is progressing on this.A6. Work is progressing on this.

4 420

Very high

CN1. Development of NCL-wide escalation process for winter 2017/18 CN2. NCL winter workshop on 27 September to align plans across A&E Delivery Boards.CN3. Development of further plans for winter 2017/18 to ensure resilience

CN1. NCL wide escalation process;CN2. Notes of workshop;CN3. Plans.

JCC 13


Management of winter pressures to support recovery of A&E waiting time standard and protect capacity for delivery of cancer and referral-to-treatment waiting time standards

Ensuring that management of winter pressures supports recovery of waiting time standards for A&E and cancer and protects capacity for elective pathways (Threat)

Cause: if we are unable to manage non-elective flows within planned hospital and community capacity to meet winter pressures

Effect: There is a risk that patients may receive sub-optimal care and long waiting times leading to the local system missing waiting time standards for A&E and referral-to-treatment. Historically capacity to meet cancer waiting time standards has been successfully ring-fenced.

Impact: Patients may remain in inpatient placements longer than anticipated as community care packages are developed.

C1. Establishment of A&E Delivery Boards with representation across health and care system C2. Establishment of NCL Urgent and Emergency Care (UEC) BoardC3. STP work streams for urgent and emergency care established for long-term sustainability.C4. Winter plans for 2017/18 prepared by each A&E Delivery BoardC5. Recovery plans submitted by each A&E Delivery Board to regain A&E four-hour waiting time standardC6. See JCC2 - recovery of A&E four-hour waiting time standardC7. Supplementary winter plans submitted by each A&E Delivery Board to NHS England and NHS Improvement in December 2017

C1. Meeting papers and minutes from A&E Delivery BoardsC2. Meeting papers and minutes from UEC Board .C3. Work streams plans and QIPP monitoring reportsC4. Plans submitted and reports/dashboards monitoring progress.C5. Plans submitted and reports/dashboards monitoring progress.C6. See JCC2C7. Funding confirmation for priority supplementary schemes from NHS England

Average

4 5

154 of 186



Place


Rating (Current)



Likelihood (Target)

Rating (Target)

Risk level (Target)

3 3 9

High

Very High

CN1. Receipt of Royal Free London remedial action planCN2. Build more effective early warning system for long waits CN3. Development of planned care initiatives in the STP to support delivery of elective pathwaysCN4. Agreement of contract terms including tariff for Clinical Advice and Navigation.CN5. Ensure payment for waiting list backlog consistent with marginal rates set in the contractCN6. Understand impact of winter planning mutual aid on elective waiting time performance

CN1. Plan;CN2. Growth in long waits including waits over 52 weeks (for which clinical harm reviews are undertaken)CN3. STP service developments offset demographic growthCN4. Clinical Advice and Navigation requires a different tariff to outpatient referralCN5 Under performance in 2017/18 due to backlog recouped at marginal rate, pay for backlog clearance at marginal rate if falls into 2018/19CN6. Trust plans to free-up clinical capacity from elective pathways to support winter pressures

A1. Continue to work with UCLH and Royal Free London on delivery of remedial action plansA2. Continue to work with providers to ensure sustainable delivery including work through the STPA3. Develop activity plans for 2018/19 for sustainable deliveryA4. Develop tariff arrangements for Clinical Advice and Navigation

A1. Updated Remedial Action Plan received from Royal Free London in March 2018. Continuing to monitor remedial action plans through contract meetings. A2. Action completed. Development of planned care initiatives for 2018/19 are completed. A3. Development of activity plans for 2018/19 underway taking into account national planning guidance that waiting lists should be maintained at current levels as a minimum.A4. Draft tariff agreed by commissioners which will be shared with providers.

A1. 31.03.2018A2. 30.11.2017A3. 23.03.2018A4. 23.03.2018.

C1. Meeting papers and notes.C2. Agreed remedial action plan C3. STP Project Initiation Documents (PIDs)C4. Draft remedial action plan

Average

4 4 16JCC 20


18-week referral-to-treatment waiting time standard is met

Delivery of referral-to-treatment (RTT) waiting time standard (Threat)

Cause: There may be insufficient capacity within the system, and inefficiencies along pathways.

Effect: There is a risk that the system may be unable to cope with the level of demand and has limited resilience to unexpected events.

Impact: This may result in people not receiving treatment within 18 weeks of referral from their GP with potential adverse impact on their health outcome.

C1. Contract governance arrangements established to cover performance.C2. Remedial action plan agreed with UCLH. C3. Planned Care work stream considering demand management schemes to support RTT delivery including Clinical Advice and Navigation. C4. Remedial action plan received from Royal Free London but with recovery of the waiting time standard targeted by August 2018. CCGs and NHS Improvement are challenging the Trust for a faster recovery.

4 4 16 high

JCC 18

Performance and Acute Commissioning

deficit in line with planning assumptions

Impact: Delivery of our STP developments is slowed down and impact reduced. Greater local resource is taken up with assurance processes

4 5 20 high

155 of 186

APPENDIX 4.1.3

Ref Risk Category Potential impact Date Opened

Inherent Likelihood

Inherent Impact

Inherent Risk Score Mitigation Owner Residual

LikelihoodResidual Impact

Residual Risk Score Next action / comments

1

Co-C

omm

issioning

Conflicts of InterestRisk that there may be an actual or perceived conflict of interest. This is particularly the case for GP members of the Committee where their judgements as a commissioner could be, or be perceived to be, unduly influenced and impaired by their own concerns and obligations as a provider.

15-Jul-16 3 4 12 A register of interest is in place and is published with the papers for every Committee meeting.

Declarations of interest requested at start of each Committee and recorded in formal minutes.

The Committee is only quorate if it has a lay member and officer majority. Quoracy is supported by options for co-option to avoid conflicts of interest.

The NCL Conflicts of Interest Policy was updated to reflect this new guidance in November 2016.

NHS England / CCGs

3 2 6 NHS England have published new conflicts of interest guidance for CCGs (June 2016).Completion of mandatory training by Committee members.

2

Co-C

omm

issioning

Governance and Operations Cause and Effect1) NHSE financial responsibilities may cause cost pressures on CCG budgets. 2) Risk of additional work without correlating resources correctly identified and aligned to the activity. 3) Unintended change to CCGs relationship with member practices where CCG becomes a decision maker over contractual matters for practices

06-Mar-17 4 5 20 Full delegation for all five CCGs from April 2017. Memorandum of Understanding between NHSE and CCGs drafted to support delegation of primary medical services budgets. Memorandum sets out responsibilities for CCGs and NHSE under delegated conditions.

Robust representation on Committee from all CCGs enables management of risk resources.

Bi-monthly update to CCG Governing Bodies through minutes of the meetings and Governing Body and Committee membership overlap

Finance reports to the Joint Committee established, reporting on fully delegated budgets. Headroom in financial position across the five CCGs in 2017/18, although differential across the CCGs.

Agreement of local budget setting and risk-share arrangements to Governing Bodies in November 2017.

London Primary Care Board established to align work of CCG d NHS E l d

Director of Performance and Acute Commissioning

3 4 12 Standard Operating Procedure developed between NHSE and London STPs

Developing NCL commissioning arrangements will need to take account of local resources for primary care development.

9

Primary C

are Provision

Loss of Service Provider without notice due to lack of notice or regulatory intervention (CQC, GMC, NHSE)There is a risk that patients will not be able to receive services or that they will seek care from other providers including- U&EC service providers-other GP practicesthis is unsafe and has system and financial impact for commissioners and providers

01-May-16 4 5 20 NHSE undertakes assessment of practice resilience to identify those at risk of failure

Resilience support built into CCG primary care commissioning plans for 2017/18 and beyond

NHSE shall accelerate normal list dispersal arrangements to support registration

NHSE and CCGs can accelerate processes to appoint a care-taker or "step-in" provider

Terms of reference for the Committee include provision for urgent and immediate decision-making between Committee meetings

NHS England / CCGs

3 3 9 Development of plans for primary care at scale for 2018/19 to develop the Resilience Programme. Plans will be supported by GP Forward View monies.

Development of a standard operating procedure (SOP) to address financial support that can be offered.

CCGs may develop solutions as part of their provider development and commissioning intentions, including through development of GP Federations

To work with NHS and Capita to reinstate a process of allocation for vulnerable patients

Development of IT solutions to allow for service provision from other sites

North Central London Primary Care Joint Committee Risk Register as at April 2018

156 of 186


Inherent Likelihood

Inherent Impact




12

Primary C

are Provision

Variation in Primary Care Quality & Performance Across NCLLack of granularity in current standard report to Primary Care Joint Committee makes it difficult to understand areas of concern in a meaningful way. There is a risk that the current variation in the quality and performance of primary care services in NCL will not be addressed effectively and in a timely manner.

01-May-16 4 3 12 An NCL Sustainability and Transformation Plan has been developed as part of a 5 year plan to reduce variation across NCL and to improve the quality of care provided to patients.

NHSE identifies poor performance using published data on performance and works with CQC and CCG's to performance manage practices where safety is a concern

The NCL Primary Care Joint Committee has agreed the establishment of a working group to review 'what good looks like' with regards to how quality and performance is monitored across NCL.

NHSE has established a London working group to improve the information provided to decision makers (Committees, providers and commissioners)

NHS England / CCGs

4 3 12 Implementation of Care Closer to Home Integrated Networks (CHINs) and Quality Improvement S Teams (QISTs) through the Care Closer to Home STP workstream.

Development of performance report to incorporate qualitative aspects of performance. London QSAG report adopted for Primary Care Committee-in-Common this will be further developed by adding local reports.

Development of refreshed primary care strategy for NCL has a focus on reducing unwarranted variation and reducing inequalities

Plans for utilising primary care growth monies in 2018/19 being developed and will come to the Committee in June 2018.

13

Primary C

are Provision

Primary care workforce developmentIf the CCGs are ineffective in developing the primary care workforce then this may have an adverse impact on the delivery of the primary care strategyThis could mean that for example, patients with long term conditions are not fully supported in primary care and require more frequent hospital care.

06-Mar-17 4 3 12 The education programme for GPs, practice nurses and practice staff.

The primary care team is now fully established, and Assistants Director (8d) post recruited to.

Development funding in primary care strategy for practice managers, practice nurse and practice-based pharmacists.

Creation of blended roles for urgent care developed through Community Education Provider Networks (CEPN) Primary Care monies used to establish practice based pharmacists and potential for physiotherapists too subject to NHSE release of investment monies.

Establishment of STP workforce workstream

Islington CCG 4 3 12 A programme for practice nurses to enhance deliver of the '6 C' strategy is being scoped.

The emergence of the GP federation and a review of locally commissioned services will help meet the development and support needs of member practices and enable a streamline of commissioning to ensure resilience and equity. Develop framework for CCGs to work with respective Federations.

Development of the refreshed primary care strategy has a focus on workforce including retention, skill-mix, and portfolio careers

14 Primary Care Provision

Alternative Primary Medical Service Cause: A temporary provider for services in Camden, Enfield, Haringey and Islington has not been commissioned as planned in March 2016. A procurement to secure a permanent NCL provider with effect from 01/04/17 has not yet commenced as planned in March 2016. Effect: Although less than 100 patients are affected, there is a risk and impact of no service being available for these patients.Impact: There is current no provider of services in Camden and Islington. The Haringey provider has no premises from which to deliver the service and the Enfield provider will cease providing services on 31/03/17.

02-Mar-17 5 4 20 NHSE undertakes an assessment of patient impact and risk

NHSE and CCGs to accelerate processes to appoint a care-taker or "step-in" provider for Camden. Haringey and Islington

Implement communication and engagement plan

Temporary service in place for Camden, Islington and Haringey residents. Notify relevant patients of mobilising interim service for the three CCGs (service in place for Barnet and Enfield)

NHS England / CCGs

3 4 12 NCL CCG procurement underway based on London-wide service specification.

15 Primary Care Provision

PMS ReviewCause: Responsibility for completing PMS Reviews now delegated to CCGs to complete by 1st October 2017.Effect: There is a risk that there is insufficient time and capacity to complete the PMS review process by the 1st October 2017 deadline. There is also a risk that the funding required to deliver an equitable offer in general practice will not be available leading to the destabilisation of practices.Impact: CCG implementation of SCF and STP proposals are compromised due to delay in releasing premiumGMS practices and their patients are not able to access premium funding.This may create uncertainty for practices and delay additional investment in primary care.

03-Mar-17 5 3 15 NCL CCGs to complete a baseline assessment of impact on practices.

Baseline assessment to inform financial modelling of impact on PMS practices and future commissioning intentions.

PMS Oversight Group established for NCL CCGs. Transition period for PMS and GMS equalisation agreed.

NCL CCGs commissioning intentions will aim to minimise impact of PMS reviews on practices while delivering equalisation across GMS and PMS.

Commissioning intentions for all 5 CCGs signed off by primary care committee-in-common, and by NHS England and Local Medical Committee through London-wide process.

Contract variations sent to all PMS practices for signature by end of May 2018.

PMS transition to start across NCL CCGs in April 2018

NCL CCGs 3 3 9 Work with PMS practices to secure contract variation sign-off by the end of May 2018.

Agreed that the PMS transition process will commence on 1 April 2018.

Implement commissioning intentions for 2018/19 across all practices in North Central London

157 of 186


Inherent Likelihood

Inherent Impact




16 Fully Delegated Commissioning

Embedding of NHSE Team into STPThe impact of new NCL commissioning arrangements and embedding of the NHSE team with a vacant Head of Primary Care role may result in the loss of its core knowledge base and continuity. This could significantly reduce the effectiveness of the Primary Care Committee and how the committee works with the NHSE Primary Care Commissioning Team.

19-Apr-17 4 4 16 Only one change in Primary Care Commissioning team means that continuity and knowledge base of team is preserved.

Recruitment to Head of Primary Care for NCL team completed

Establishment of Primary Care Committee-in-Common

Joint workshop for primary care held on 14 December 2017

Director of PCC (NHSE)/NCL Director of Performance and Acute Commissioning

Enfield Commissioning Workstream Lead

3 3 9 Develop work programme that better aligns intentions for core and enhanced primary care: - Primary care team support for care closer to home strategy;

- Opportunity to better align incentives for primary care – Quality Outcomes Framework (QOF), Locally Commissioned Services (LCS), and GP Forward View:

- Stronger links into London-wide work on primary care.


Committee in common QuoracyIn light of the changes to the terms of reference for the Primary Care Committee in common that require quoracy attendance to be met for all 5 CCGs, there is an increased chance of the meeting being inquorate and therefore unable to make decisions. This will result in an increase in urgent decisions being taken outside of the committee forum reducing the transparency and scrutiny of decisions and potentially impacting on the consistent approach proposed across the 5 CCGs.

19-Apr-17 4 3 12 Committee membership has been formally defined in advance and approved by CCG Governing Bodies.

Terms of reference incudes provision for co-option to support quoracy

2 Independent GPs have been included in the membership to provide co-option arrangements for CCGs unable to field a clinical representative who wish to delegate this responsibility to an alternative clinical lead.

Committee meeting schedules are reviewed at each meeting to identify in advance issues in attendance.

NCL Director of Performance and Acute Commissioning can act as Executive lead for any of the 5 CCGs.

Dates for 2018/19 meetings set to support quoracy

Committee Secretary

2 3 6 CCGs to clarify deputies to attend for members.

Permanent recruitment to CCG Primary Care Commissioning Teams provides a more stable Executive Officer presence.

Schedule of meetings agreed for 2018/19 to maximise attendance.


Primary Care Support EnglandThere is a risk that the NHS England Primary Care Support Services functions (commissioned and managed by NHS England) result in impact on business continuity of GP services, quality of service to primary care users and cost pressures to fully delegated CCGs

19-Apr-17 4 4 16 Inclusion of independent contractors in operational review group for London.

Monthly report by independent contractor groups (LMC) to NHS England-London primary care team on recurrent issues being reported by contractors in relation to PCSE Increasing scrutiny and validation of this action on a case by case basis by NHS England

Director of Primary Care Commissioning (NHS England)

4 4 16 Standing agenda item on PCCCC agenda comprising regular update from risk owner on current issues/cases for NCL and progress to date with resolution of these.

158 of 186

Ref Risk Category Potential impact Date OpenedInherent Likelihoo

d

Inherent Impact

Inherent Risk

ScoreMitigation Owner

Residual Likelihoo

d

Residual Impact

Residual Risk

ScoreNext action / comments

10

Primary C

are Provision

PMS Contract ReviewRisk of delays due to ongoing negotiations with key stakeholders.CCG implementation of SCF and STP proposals are compromised due to delay in releasing premiumGMS practices and their patients are not able to access premium funding This may create uncertainty for practices and delay additional investment in primary care.

01-May-16 5 3 15 Extension to the deadline has been agreed by NHS England which will support alignment with the NCL Sustainability and Transformation Plan.

National guidance issued to CCGS

NHS England / CCGs

4 2 8 Ongoing discussions are underway with key stakeholders regarding the timeline for completing PMS contract reviews.

Risk superseeded by Risk no. 15

11

Primary C

are Provision

PMS Review (Threat)Cause: If NHS England fail to successfully complete the PMS Review.Effect: There is a risk that the funding required to deliver an equitable offer in general practice will not be available leading to the destabilisation of practices.Impact: This may impact on core PMS funding resulting in CCGs being unable to deliver the Primary Care Mandate commitment - a consistent offer for patients in general practice in Camden.

Risk superseeded by Risk no. 15

3

Service Transformation / STP

Regeneration projectsImpact on local population and practices' ability to absorb increase in population.Issues: 1. Alignment of NHS strategic planning with LA planning timescales2. Affordability of new premises which will initially have void capacity

01-May-16 2 5 10 - CCG Estates Strategies in place

- Engagement with local stakeholders, developers and council planners.

- Impact assessment and review of GP services in the area.

- CCGs have recently submitted bids for additional funding through the Estates and Technology Transformation Fund (June 2016).

CCGs 2 2 4 CCGs are awaiting outome of recently submitted bids for additional funding through the Estates and Technology Transformation Fund.

6

Primary C

are Provision

Resignation of a provider where premises will not be available to reprovide the service resulting in a list dispersalImpact to registered patients and the local population. Issues: 1. Possible disruption of service continuity for patients who need to register with a new practice2. Increased workload for receiving practices who may already be under strain

01-May-16 4 2 8 Processes in place to:1. identify vulnerable patients who can be allocated to a new practice2. provide information to patients to support re-registration3. additional capitation payments for new patients4. implement communication and engagement with patients and other stakeholders

NHS England/CCG

4 1 4 Options and decisions relating to resignation of providers are brought to the NCL Primary Care Joint Committee. Where required, an urgent decision making process is in place.Resilience Programme is considering how receiving practices can be supported in the future. CCG's may address sucession planning as part of STP and provider developmentDevelopment of IT solutions to allow for service reprovision from other sites

7

Primary C

are Provision

Resignation of a provider with insufficient notice to appoint a new provider under long term APMS arrangementsThe current lead time to appoint under competitive procurement is circa 12 months whilst notice periods are either 3 or 6 months. If this is not addressed there will be a service gap necessitating the need for high cost care-taking arrangements and uncertainty for patients

01-May-16 3 3 9 Joint commissioners should ensure that care-taking arrangements are for fixed term whilst a procurement is initiatied. Where possible caretaking providers should be directed to improve the quality and/or viability of the service.

Implement Communication and engagement plan

NHS England/CCG

2 2 4 CCG's may address via provider development workstreams to promote new operational models that enhance viability.Development of IT solutions to allow for service reprovision for other sites

8

Primary C

are Provision

Resignation of a strategically essential provider with a small listThe list size means that procurement is likely to be unsuccessful due to the viability of the service

01-May-16 2 4 8 London APMS programme undertakes a strategic assessment and a viability assessment of all proposed procurements. This will establish whether there is a need to maintain the service and if so, the viability under APMS arrangements. Where viability is an issue but can be addressed through service growth or development, then support payments may be offered to the bidders.

NHS England/CCG

2 2 4 CCG's to address via provider development workstreams to promote new operational models that enhance viability

North Central London Primary Care Joint Committee Closed Risks

159 of 186

NCL Risk Register April 2018 App 4.1.4



Place

Consequence

Likelihood

Rating (Current)

Risk level

Controls Needed Evidence of Controls Needed Actions Action Completion Date Update on Actions

Consequence

Likelihood

Rating (Target)

Risk level (Target)

NCL 1Will Huxter, NCL Director of Strategy

Successful delivery of the STP transformation agenda

Delivery of the Transformation Agenda (Threat)

Cause: If the STP does not have sufficient clinican and political support and suitable capacity and resources

Effect: There is a risk that the STP will not deliver the expect financial or quality benefits and that services are not appropriately integrated

Impact: This may result in a system wide financial deficit and deterioration in clinical quality which will negatively impact on patient care and reputational damage.

C1. Clinical leaders are in place across workstreams;C2. NCL wide Health and Care Cabinet established to oversee plans;C3. Recruitment to STP programme team is in progress;C4. QIPP Planning processes in NCL aligned with STP;C5. On-going senior enagement with local councillors and with the Joint Health and Overview Scrutiny CommitteeC6. STP programme infrastructure in place including programme board with senior representation from parter organisations and a sector wide finance group;C7. Robust planning process in place including regular reviews with NHS England and NHS Improvement;C8. Commissioning intentions;C9. Service business cases and project plans;C10. CCG commissioning teams and Provider teams in place;C11. Clinically led STP delivery plans in place.

C1. Terms of reference and project documentation;C2. Papers;C3. Job adverts and employment contracts;C4. Finance reports, CCG QIPP plans.C5. Meeting papers.C6. Terms of reference and meeting papers.C7. Programme delivery plans, notes and minutes from meetings;C8. Governing Body papers; C9. Business case and project plan papers;C10. Employment contracts;C11. Documents and papers.

Average

4 3 12

High

CN1. On-going work to link to new CCG operating models is in progress.CN2. Scope and develop provider focussed efficiency workplan;CN3. Complete recruitment to STP programme team.CN4. Strengthen Health and Care Cabinet and link back to partner organisationsCN5. Improve tracking of benefits across programmes.

CN1. Papers, Standing Operating Procedures;CN2. Provider focussed delivery plan;CN3. Employment contracts;CN4. Refreshed Terms of Reference and communications plans;CN5. Benefit tracker.

A1. Continue to work with CCGs on linking CCG operating models to STP plans.A2. Scope and develop provider focussed efficiency workplan;A3. Complete recruitment to STP programme team;A4. Revise terms of reference for Health and Care Cabinet;A5. Develop communications plan;A6. Develop new programme highlight reports containing benefits tracker.

A1. 14.02.2019A2. 01.04.2018;A3. 01.09.2018;A4. 30.05.2018;A5. 30.05.2018;A6. 30.05.2018

A1. Alignment on QIPP is completed. Alignment on risk management is underway;A2. SRO appointed and areas of scoping chosen;A3. 80% posts recruited to substantively;A4. Terms of reference under review;A5. Communication manager recruitment in progress;A6. A review of this is in progress.

4 2 8

High

NCL 2

Paul Sinden, Director of Performance and Acute Commissioning

Maintaining System Stability

Sustainability of Fragile Services (Threat)

Cause: If the STP does not recognise the need for system stability across services and providers

Effect: There is a risk that smaller and fragile services become unsustainable

Impact: This may result in disruption to patient services and system instability.

C1. NCL Joint Commissioning Committee in place which considers issues of system stability;C2. Relevant STP programme boards feed into service plans where appropriate;C3. CCGs have commissioning teams in place;C4. Governing Bodies focus on issues when they arise;C5. CCG commissioning intentions;C6. Commissioners feed into development of workstream plans.

C1. Terms of reference and committee papers;C2. Minutes and notes of programme board meetings;C3. Stuffing structure and employment contracts;C4. Governing Body and committee meeting papers and minutes;C5. Document;C6. Minutes and notes of programme board meetings.

Average

3 3 9

High

CN1. Strengthened oversight of totality of provider contracts: CN2. Centrally held registers of contracts in each CCG;CN3. Overview of fragile services

CN1. Completed register of contracts, named leads;CN2. Completed register of contracts;CN3. Notice from providers on service cessation for unsustainable services.

A1. Development of contract registersA2 Identification of fragile services

A1. 30.06.2018A2. 30.09.2018

A1. CCGs developing contract registers and identifying small contracts rolled forward year-on-yearA2. STP planned care workstream identifying fragile and at-risk services in providers 3 2 6

Moderate

NCL 3 Simon Goodwin, NCL CCGs CFO

Development of an Effective STP Estates Strategy

Failure to Develop an Effective STP Estates Strategy

Cause: If the STP partners do not develop an effective estates strategy for the STP which takes into account the resources within the system and the current limitations of national legislation

Effect: There is a risk that the Estates Strategy does not deliver the most effective use of resources and impacts on services and staff

Impact: This may result in wasted resources, opportunity costs, reputational damage and difficulties in recruiting and retaining high quality staff.

C1. STP Estates Board established;C2. STP SRO appointed;C3. Working with STP partners, regulators and the London Estates Board to understand the key objectives.

C1. Terms of Reference, meeting papers and notes;C2. Papers and notes of meeting;C3. E-mails, papers and notes.

Average

3 3 9

High

CN1. Develop STP estates strategyCN2. Ensure appropriate link between STP Estates Board and NCL CCG Governing Bodies.

CN1. Estates Strategy paper;CN2. Governance chart, Governing Body papers and reports.

A1. Develop draft STP estates strategy for engagement with key partners;A2. Establish appropriate governance arrangements for the STP Estates Board

A1. 30.07.2018;A2. 31.03.2018

A1. Initial draft NCL estates workbook completed – system engagement underway with next draft due 7.2018 A2. Strategy outlines proposed Terms of Reference and governance.

3 2 6

Moderate

NCL 4

Helen Pettersen, NCL CCGs Accountable Officer

Effective Engagement with Patients and the Public

Failure to Effectively Engage with Patients and the Public (Threat)

Cause: If the STP partner organisations do not effectively engage with patients and the public as part of the STP process

Effect: There is a risk that the STP process is not properly understood by patients, the public and their representatives causing them to disengage

Impact: This may result in service design not taking proper account of the needs of local people, reputational damage and a blcokage to integrated services.

C1. STP governance structure which includes significant clinical and public oversight;C2. Health and Well Being Boards;C3. Joint Health Overview and Scritiny Committee;C4. CCG Governing Bodies;C5. Provder Board of Directors and Council of Governors where appropriate;C6. Local Councils and Councillors;C7. NCL Advisory Board including councillors, Healthwarch and the Chairs of STP partner organisations;C8. Health and Care Cabinet with extensive clinical leadership;C9. CCGs and Providers have their own communications and engagement teams and local patient and public engagement mechanisms and meetings;C10. Named Communications Lead in each CCG.

C1. STP plan;C2. Papers and minutes of meetings;C3. Papers and minutes of meetings;C4. Papers and minutes of meetings;C5. Papers and minutes of meetings;C6. Papers and minutes of meetings;C7. Papers and minutes of meetings;C8. Papers and minutes of meetings;C9. Contracts of employment, meeting papers and notes;C10. Employment contracts.

Average

4 3 12

High

CN1. Recruit to Head of STP Communications role;CN2. STP communications and engagement plan;

CN1. Employment contract;CN2. Finalised STP communications and engagement plan.

A1. Recruit Head of STP Communications A2. Draft STP Communcations and Engagement Plan.

A1. 01.09.2018;A2. 30.05.2018

A1. A1. Head of Ccomms due to start in May 2018;A2. This will begin once the Head of STP Communications is in role.

4 2 8

High

NCL 5

Helen Pettersen, NCL CCGs Accountable Officer

Achievement of STP Year 2 Objectives

Purdah Period and the Impact of Local Elections (Threat)

Cause: If there is an inability for decision making at the local Councils due to the Purdah period or if there is signficant change of policial leadership and direction of travel due to local council elections in 2018

Effect: This is a risk that the Council cannot make key decisons as an STP partner organisation and/or that a change in personnel and policy within one of more local councils

Impact: This may result in a delay in the implemntation of the STP workstreams and/or the need to develop and strengthen new relationships to preservice continuity of delivery.

C1. Continued work with the Joint Health Oversight and Scrutiny Committee;C2. Continue to work with local authroity partner organisations;C3. Continue to work with and strengthen relationships with local councillors;C4. Continue to effectively engage.

C1. Papers and minutes of meetings;C2. Papers and minutes of meetings;C3. Papers and minutes of meetings;C4. Papers and minutes of meetings, communications, e-mails.

Average

4 3 12

High

CN1. An STP induction programmeCN2. Ensure clearer narrative between STP programmes and postive impact on local people;CN3. STP Communications and Engagement Plan;CN4. Quickly build relationships with new local councillors;CN5. Involve existing and new local councillors in on-going development of STP.

CN1. Register of attendance, induction pack;CN2. Communications;CN3. STP Communications and Engagement Plan document;CN4. E-mails and correspondence;CN5. E-mails, correspondence and papers.

A1. Create STP indiction pack;A2. Develop KPIs for workstreams which demonstrate positive impact on local people;A3. Draft STP Communcations and Engagement Plan;A4. Identify and make contact with new councillors after local elections in 2018;

A1. 03.05.2018;A2. 03.05.2018;A3. 30.05.2018;A4. 04.05.2018

A1. Action in progress;A2. Action in progress;A3. This in being developed;A4. This will be completed after the results of the local elections are announced.

3 3 9

High

NCL 6Will Huxter, NCL CCG Director of Strategy

Ensuring Effective Decision Making

Lack of Clarity on STP and NCL CCG Governance Arrangements (Threat)

Cause: If there is a lack of clarity on STP and NCL CCGs' governance arrangements;

Effect: There is a risk of confusions as to where decisions are made and that decisions are not made in the correctly or at all

Impact: This may result in decision freeze or in decisions being made ultra vires which may result in signficant delay in delivering integrated services due to an inability to act or legal challenge.

C1. STP Head of Programme Management in place;C2. Interim NCL Head of Governance and Risk in place for the NCL CCGs;C3. STP governance structure in place;C4. CCG and Provider organisations' governance structures in place;C5. STP website containing STP structure and minutes of STP Programme Delivery Board and Health and Care Cabinet meetings;C6. STP governance handbook in place.

C1. Employment contract;C2. Employment contract;C3. STP Plan, structure chart and papers and minutes of meetings;C4. Governance documentation, structure charts, papers and minutes of meetings;C5. Webiste;C6. Document.

Average

3 3 9

High

CN1. STP Communications and Engagement Plan;CN2. Recruit to Head of STP Communications role;CN3. A document clearly outlining STP governance and how it links with STP partners' governance structures;CN4. Recruitment to all governance and Board Secretary posts on NCL CCG Corporate Services structure.

CN1. STP Communications and Engagement Plan document;CN2. Employment contract;CN3. Governance document.CN4. Contracts of employment.

A1. Draft STP Communcations and Engagement Plan;A2. Recruit Head of STP Communications;A3. Create document setting out STP governance and how its links with STP partner organisations' governance structures.A4. Complete recruitment to NCL CCG Corporate Services governance roles.

A1. 30.05.2018;A2. 01.09.2018;A3. 30.04.2018A4. 30.06.2018

A1. This is being developed;A2. Head of Communications due to start in May 2018;A3. This work is due to begin.A4. Board Secretaries recruitment completed. Interim NCL Risk Manager is in role and interviews are being held for interim Governance Lead. 2 2 4

Moderate

NCL Risk Register

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NCL 7Will Huxter, NCL CCG Director of Strategy

Delivery of the STP Digital Agenda

Failure to Deliver the Digital Agenda Across the STP (Threat)

Cause: If the STP partners do not deliver the digaital agenda across the STP;

Effect: There is a risk that the STP partners will not be able to deliver the Five Year Forward View and the underlying digital infrastructure such as integrated ditigal care records and will be unable to deliver the required QIPP savings

Impact: This may result in a negative impact on investments across the STP partners, a negaitve impact on the quality of patient care, reputational damage and an inability to meet the required national targets.

C1. Ditigal Programme Board in place;C2. Digital road map between STP partner organisations;C3. NCL IG Group in place;C4. Health Information Exchange ('HIE') delivery plan and Population Health Management ('PHM') delivery plan being developed;C5. Priorities for 2018-19 agreed with SRO being Health Information Exchange ('HIE') and population health management.

C1. Terms of Reference, meeting papers;C2. Terms of Reference, meeting papers;C3. Terms of Reference, meeting papers;C4. Papers;C5. Minutes from February 2018 STP Delivery Board.

Average

4 3 12

High

CN1. STP Digital Strategy;CN2. Clear digital governance structure;CN3. Clear differentiation between commissioner and provider digital roles and responsibilities.

CN1. Digital Strategy paper;CN2. Digital governance structure paper;CN3. Agreement between STP partner orgsnisations showing clear responsibilities.

A1. Develop Digital Strategy;A2. Continue to develop HIE and PHM Delivery Plan;A3. Develop Digital governance structure;A4. Develop agreement between STP partners on responsibilities;A5. HIE and PHM delivery plan to be presented to May 2018 STP Delivery Board.

A1. 30.03.2019;A2. 30.05.2018;A3. 30.05.2018;A4. 01.06.2018;A5. 30.05.2018

A1. This work is due to begin;A2. This work is being developed;A3. This work is being developed;A4. This work is due to begin;A5. PHM delivery plan is being drafted.

3 2 6

Moderate

NCL 9 Simon Goodwin, NCL CCGs CFO

Achiement of Finance Balance Across NCL CCGs

Delivering Financial Balance Across NCL CCGs (Threat)

Cause: If the five CCGs in North Central London fail to deliver their QIPP targets and achieve financial balance by the end of the financial year

Effect: There is a risk that the NCL CCGs will fails to meet the collective NHS England control total.

Impact: This may result in one or more CCGs being placed under legal directions or special measures, destbilisation of one or more CCGs, a negative impact on the local health economy and loss of influence of quality of patient care.

C1. Each CCG has QIPP schemes in place and delivery plans;C2. QIPP planning and delivery is overseen and scrutinised by Governing Bodies and relevant committees;C3. NCL Senior Management Team are QIPP focussed;C4. QIPP managers are in role;C5. Deloitte review of QIPP completed;C6. CCGs working with providers through the STP to deliver QIPP savings;C7. Contractual levers and sanctions;C8. Addtional strategic QIPP capacity in place;C9. Single NCL CFO in place;C10. Financial planning undertaken at NCL level using consistent methology;C11. NCL finance leads meet on a monthly basis;C12. CCG Finance and Performance Committees (and equivalent)

C1. QIPP plans and papers;C2. Governing Body and committee papers and minutes;C3. Meeting papers, minutes and notes;C4. Contracts of employment;C5. Review outcomes document; C6. STP QIPP plans, meeting notes and minutes;C7. Contracts with providers;C8. Contract for services;C9. Employment contract;C10. Plans;C11. Papers;C12. Papers and minutes of meetings.

Average

4 5 20

Veery High

CN1. Develop and implement a 2018-19 budget to offset potential unmitigated financial risks within each CCG;CN2. Implement 2018-19 QIPP plans.

CN1. Agreed budgets and papers;CN2. In year QIPP moniroing reports.

A1. Develop and agree the 2018-19 budgets;A2. Implent 2018-19 QIPP plans.

A1. 30.04.2018;A2. 31.03.2019

A1. 2018-19 budget planning is underway;A2. This will start at the beginning of the 2018-19 financial year.

4 3 12

High

NCL 10

Paul Sinden,NCL Director of Performance and Acute Commissioning

Successful in-housing of the multi-disciplinary contract team from North East London Commissioning Support Unit (NELCSU)

CSU In-Housing of Services (Threat)

Cause: If we do not manage the in-housing of the contract team from NELCSU successfully

Effect: There is a risk that business continuity is disrupted which may have a significant negative impact on services, staffing, organisational stability, finance, performance, and contract delivery.

Impact: This may result in a reduction in contract delivery. an increase in costs, downturn in performance, reputational damage and a potential negative impact on patient services.

C1. Senior Management Team with a high degree of experience and expertise in CSU contracting.C2. Programme Director in place;C3. Working Group in place with Governing Body oversight;C4. Project Plan in place.C5. Contingency for additional support if needed.C6. Signed SLA in place for 2017/18 and 2018/19 as a baseline

C1. Employment contracts.C2. Service Agreement.C3. Minutes and papers of meetings.C4. Project plan document.C5. WAP Process.C6. Signed service level agreement

Strong

4 2 8

High

CN1. Business case for NHS England to be developed.CN2. Business case to be approved by NHS England.CN3. HR engagement process;CN4. Communications and engagement plan.

CN1. Business case a formal part of process to in-house CSU services;CN2. Approval from NHS England required before HR consultation process can begin.

A1. Continue to implement the project plan;A2. Draft the business case for NHS England;A3. Present the business case to NHS England;A4. Develop supporting HR engagement process to start on approval of business case by NHS England;A5. Development of communications and engagement plan to support the HR process;A6. Continue to refine stranded costs included by NELCSU in the business case.

A1. 01.07.2018A2. 28.02. 2018A3. 30.04.2018A4. 30.04.2018A5. 30.04.2018

A1. Weekly project team meetings are held and going to plan;A2. Draft business case circulated;A3. Business case is on track for submission by revised target date;A4. Development of HR process underway;A5. Plan in development;A6. Negotiations overseen by weekly project group meeting.

1 2 2

Low

A1. This work is due to begin;A2. This work is due to begin;A3. This work is due to begin;A4. This was is being developed;A5. The HR team has been fully recruited to with all team members being in place by end of June 2018. Recruitment for the Organisational Development roles is under way.

2 1 2

LowNCL 8

Ian Porter, NCL CCG Director of Corporatre Servces

Recruit and Retain a High Performing Workforce

Recruitment and Retention a High Performing Workforce (Threat)

Cause: If the NCL CCGs are unable to recruit and retain a high performing workforce;

Effect: The NCL CCGs will be unable to deliver their stategic objectives and operational goals;

Impact: This may result in a negivtive impact on the delivery of CCG workstreams, integrated care and patient services.

C1. STP is developing priorities for key clinical and staff providing care;C2. NCL CCG wide Senior Management Team in post;C3. Chief Operating Officer for each CCG in post;C4. Chief Operating Officers are recruiting to vacant posts on the establishment;C5. NCL SMT are fostering a culture of openness and transparency;C6. Executive leadership development is under way;C7. NHS Staff Survey and acting on the results;C8. NCL HR Team to support the NCL SMT and CCG Chief Operating Officers;C9. Recruiting to NCL HR roles;C10. NCL wide HR policies;C11. Increased focus on Organisational Development;C12. HR and OD groups operating locally in some CCGs and are being developed for all CCGs;C13, Equality, Diversity and Inclusion work is being developed across NCL;

C1. Papers;C2. Employment contracts;C3. Employment contracts;C4. Job adverts, employment contracts;C5. Papers, communications;C6. Papers;C7. Results paper and plans;C8. Employment contracts;C9. Job adverts and Job Descriptions;C10. Policy documents;C11. Papers, communications;C12. Meeting papers and notes;C13. Papers.

Strong

3 2 6

Moderate

CN1. Develop NCL Organisational Development strategy;CN2. Develop specific workforce strategy/plans for each CCG which includes talent management and succession planning;CN3. Develop organisational development strategic plan;CN4. Develop Equality, Diversity and Inclusion Strategy for 2018-19 ;CN5. Complete HR recruitment.

CN1. NCL Organisational Development strategy document; CN2. Strategy/plan documents;CN3. Strategic plan document;CN4. Equality, Diversity and Inclusion Strategy document;CN5. Employment contract.

A1. Develop NCL Organisational Development strategy;A2. Develop specific workforce strategies/plans for each CCG;A3. Develop organisational development strategic plan;A4. Develop Equality, Diversity and Inclusion Strategy for 2018-19 ;A5. Continue to recruit to HR and Organisational Developlment roles.

A1. 30.08.2018;A2. 30.08.2018;A3. 30.08.2018;A4. 30.05.2018;A5. 28.04.2018

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Appendix: 4.1.5

Risk Scoring Key This document sets out the key scoring methodology for risks and risk management.

1. Overall Strength of Controls in Place There are four levels of effectiveness: Level Criteria Zero The controls have no effect on controlling the risk. Weak The controls have a 1- 60% chance of successfully controlling the risk. Average The controls have a 61 – 79% chance of successfully controlling the risk Strong The controls have a 80%+ chance or higher of successfully controlling the risk

2. Risk Scoring

This is separated into Consequence and Likelihood. Consequence Scale: Level of Impact on the Objective

Descriptor of Level of Impact on the Objective

Consequence for the Objective

Consequence Score

0 - 5% Very low impact Very Low 1 6 - 25% Low impact Low 2 26-50% Moderate impact Medium 3 51 – 75% High impact High 4 76%+ Very high impact Very High 5

Likelihood Scale: Level of Likelihood the Risk will Occur

Descriptor of Level of Likelihood the Risk will Occur

Likelihood the Risk will Occur

Likelihood Score

0 - 5% Highly unlikely to occur

Very Low 1

6 - 25% Unlikely to occur Low 2 26-50% Fairly likely to occur Medium 3 51 – 75% More likely to occur

than not High 4

76%+ Almost certainly will occur

Very High 5

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3. Level of Risk and Priority Chart

This chart shows the level of risk a risk represents and sets out the priority which should be given to each risk:

LIKELIHOOD

CONSEQUENCE

Very Low (1)

Low (2)

Medium (3)

High (4)

Very High (5)

Very Low (1)

1 2 3 4 5

Low (2)

2 4 6 8 10

Medium (3)

3 6 9 12 15

High (4)

4 8 12 16 20

Very High (5)

5 10 15 20 25

1-3

Low Priority

4-6

Moderate Priority

8-12

High Priority

15-25

Very High Priority

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Item: 4.2

MEETING

NHS Islington CCG Governing Body

DATE

Wednesday 9 May 2018

REPORT NCL Audit Committee in Common and Individual CCG’s Audit Committees

LEAD DIRECTOR / GOVERNING BODY MEMBER

Ian Porter, Director of Corporate Services for NCL CCGs

AUTHOR

Andrew Spicer, NCL Head of Governance and Risk

CONTACT DETAILS

[email protected]

EXECUTIVE SUMMARY This paper sets out revisions to the Terms of Reference for each CCG’s audit committee and the NCL Audit Committee in Common. It also sets out the proposed membership and asks the Governing Body to approve these and delegate the power to appoint future members of the CCG’s audit committee to the Chair of the Governing Body. RECOMMENDED ACTION The Governing Body is asked to approve:

1. The amended Terms of Reference; 2. The membership of the CCG’s audit committee; 3. The Chair and Vice Chair of the NCL Audit Committee in Common; 4. Delegation of the power to appoint members of the CCG’s audit committee in line

with the membership requirements set out in the Terms of Reference to the Chair of the Governing Body.

Objective(s) / Plans supported by this paper: (How does this report help to deliver the CCG Strategic Goals and Quality Strategy?) This report supports the CCG in achieving all of its strategic goals by ensuring that robust governance processes are in place at the CCG. Audit Trail: This report builds on the work approved by Governing Bodies in November 2016 to support the development and delivery of their Sustainability and Transformation Plan and integrated working arrangements. A report on the NCL Audit Committee in

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Common was presented to the Governing Bodies of Camden, Enfield, Haringey and Islington CCG in January 2018 and to the Barnet CCG Governing Body in March 2018. Patient & Public Involvement (PPI): This report is being presented to the Governing Bodies of the five CCGs in North Central London which include lay members and elected clinicians. In addition, the lay members for governance and audit in each of the five North Central London Clinical Commissioning Groups were consulted. Equality Impact Assessment: This report was written in accordance with the provisions of the Equality Act 2010. Risks: This report helps to maximise the opportunities for strategic collaboration across the five North Central London Clinical Commissioning Groups and strengthens oversight and assurance of our internal control mechanisms. Conflicts of Interest: Conflicts of Interest have been managed in accordance with the NCL Conflicts of Interest Policy. Resource Implications: This report if approved will:

• Reduce duplication of effort across the five North Central London Clinical Commissioning Groups;

• Reduce the amount of internal and external auditor resource needed to carry out effective scrutiny of our internal control mechanisms;

• Better deploy resources and increase expertise, effectiveness and learning through information, knowledge and skills sharing.

• Provide the flexibility to work together or individually when it best suits the needs of an effective audit function.

Next Steps: If the recommendations in the report are approved the next step is to mobilise the NCL Audit Committee in Common with the first meeting due to take place in July2018.

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Appendix: 4.2.1

NCL Audit Committee in Common and Individual CCG’s Audit Committees

Introduction This paper sets out revisions to the Terms of Reference for each CCG’s audit committee and the NCL Audit Committee in Common. It also sets out the proposed membership and asks the Governing Body to approve these and delegate the power to appoint future members of the audit committee to the Chair of the Governing Body. Background In January and March 2018 the Governing Bodies of the five North Central London Clinical Commissioning Groups approved the harmonisation of their audit committee’s Terms of Reference, approved the formation of an audit committee in common known as the ‘NCL Audit Committee in Common’, and approved Terms of Reference for each. However, membership of these committees had not been agreed and lay members requested some additional amendments to the Terms of Reference to strengthen the quorum requirements and clarify the importance of individual audit committees in terms of accountabilities. Terms of Reference The revised Terms of Reference contain the following amendments: Paragraph Amendment Reason 1.3, 5.1, 6.1, 7.1, 8.1, 9.1, 10.1, 10.2, 11.1, 11.2, 11.3 12.1, 13.1, 13.3

Minor amendments to wording.

To emphasise the importance of individual audit committees and their accountabilities.

14.4 Inclusion of a paragraph setting out that the lay member for audit and governance from another NCL CCG will be appointed to the audit committee on a non-remunerated basis.

To clarify to basis on which the lay member for audit and governance from another CCG is appointed onto the audit committee.

17.1, 17.2 Amended the quorum requirements so that at least one member of the audit committee must be from the respective CCG for a meeting to be quorate.

This removes any risk of an audit committee being quorate without a member of the respective CCG being present.

18.1, 18.2 Minor amendments to simplify the drafting.

To make the Terms of Reference easier to read.

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31.2 Minor amendment so Terms of Reference are reviewed annually.

To increase committee effectiveness and ensure ease of operations.

Membership Under the agreed Terms of Reference the membership of each CCG’s audit committee comprises of three people who are:

• The CCG’s Governing Body lay member for audit and governance; • A Governing Body lay member for audit and governance from another NCL Clinical

Commissioning Group; • An additional member who is either:

o A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or

o A second Governing Body lay member for audit and governance from another NCL Clinical Commissioning Group who is a different person that that referred to above.

In this regard the Governing Body is asked to formally appoint their members of their audit committee. The proposed membership of each audit committee is as follows: CCG CCG’s Lay Member

for Audit and Governance

A Lay Member for Audit and Governance from another NCL CCG

Additional Member

Barnet

Dominic Tkaczyk Karen Trew Ian Bretman

Camden

Richard Strang Dominic Tkaczyk TBC

Enfield

Karen Trew Adam Sharples TBC

Haringey

Adam Sharples Lucy De Groot TBC

Islington

Lucy De Groot Richard Strang TBC

Governing Bodies are not asked to approve the membership of other CCG’s audit committees. Chair and Vice Chair of the NCL Audit Committee in Common The Chair and Vice Chair of the NCL Audit Committee in Common are important as they act as convenors of the meeting and help ensure meetings run smoothly. The Chair and Vice Chair only have voting rights on the individual audit committees that they are appointed to. It is proposed that the Chair and Vice Chair of the NCL Audit Committee in Common are: Name Role CCG Adam Sharples

Chair Haringey

Dominic Tkaczyk

Vice Chair Barnet

The NCL Audit Committee in Common will review the Chairing arrangements after 12 months. When CCG audit committees meet individually the Chair shall be the Lay Member for Audit and Governance from that respective CCG.

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Delegation to the Governing Body Chair It is a requirement that the members of the audit committee are formally appointed by the Governing Body as set out above. To maximise operational flexibility, effectiveness and preserve current practices whilst ensuring that our governance processes remain robust Governing Bodies are requested to delegate to the Chair of the Governing Body the power to appoint future members of the CCG’s audit committee in line with the membership requirements set out in the Terms of Reference. Recommendations The Governing Body is asked to approve:

• The amended Terms of Reference; • The membership of the CCG’s audit committee; • The Chair and Vice Chair of the NCL Audit Committee in Common; • Delegation of the power to appoint members of the CCG’s audit committee in line with

the membership requirements set out in the Terms of Reference to the Chair of the Governing Body.

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Appendix: 4.2.2

NCL Audit Committee in Common and Individual Audit Committees

Terms of Reference

1. Introduction 1.1 The Governing Bodies of the five Clinical Commissioning Groups in North Central London

(‘NCL’) have each established their own audit committees to critically review and report to their respective Governing Body on the relevance and robustness of the governance and assurance processes on which each relies.

1.2 The five NCL Clinical Commissioning Groups are: • NHS Barnet Clinical Commissioning Group (‘Barnet CCG’); • NHS Camden Clinical Commissioning Group (‘Camden CCG’); • NHS Enfield Clinical Commissioning Group (‘Enfield CCG’); • NHS Haringey Clinical Commissioning Group (‘Haringey CCG’); • NHS Islington Clinical Commissioning Group (‘Islington CCG’).

1.3 The NCL Clinical Commissioning Groups are working together to form and operate with a

common set of controls. To support this and provide strengthened oversight the NCL Clinical Commissioning Groups have agreed to hold their audit committees together at the same time, in the same place, with a common agenda and a common chair as a committee in common. This is known as the ‘NCL Audit Committee in Common.

1.4 The NCL Clinical Commissioning Groups have also agreed to retain the flexibility for their individual audit committees to meet by themselves where doing so best achieves an effective audit committee function.

1.5 These Terms of Reference set out the membership, remit, responsibilities and reporting arrangements of both the individual Clinical Commissioning Group (‘CCG’) audit committees and the NCL Audit Committee in Common.

2. Committees in Common

2.1 The following committees form the NCL Audit Committee in Common:

• NHS Barnet CCG Audit Committee; • NHS Camden CCG Audit Committee; • NHS Enfield CCG Audit Committee; • NHS Haringey CCG Audit Committee; • NHS Islington CCG Audit Committee.

3. Statutory Framework 3.1 The four key statutory requirements for Clinical Commissioning Group audit committees are:

Provision Requirement Section 14(M) of the NHS Act 2006 (as amended)

A governing body of a clinical commissioning group must have an audit committee

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Section 14(1) of the Clinical Commissioning Group Regulations 2012

The audit committee of a CCG Governing Body must have a chair, to be appointed by the CCG for a term to be determined by the CCG

Section 14(2) of the Clinical Commissioning Group Regulations 2012

The chair of the audit committee must be a lay person who has qualifications, exertise or experience such as to enable the person to express informed views about financial management and audit.

Section 7(3) of Schedule 1A to the NHS Act 2006 (as amended)

CCG Constitutions may include provision for the audit committee to include individuals who are not members of the governing body.

3.2 The individual audit committees and the NCL Audit Committee in Common are established in

line with legislation and with the Constitutions of each of the NCL Clinical Commissioning Groups.

4. Role of the Committee 4.1 The role of the individual audit committees and the NCL Audit Committee in Common is to

carry out the duties listed in sections 5 to 13 below. These apply regardless of whether the individual audit committees are meeting by themselves or together as part of the NCL Audit Committee in Common.

5. Integrated Governance, Risk Management and Internal Control 5.1 Each CCG’s audit committee shall review the establishment and maintenance of an effective

system of integrated governance, risk management and internal control, across the whole of the CCG’s activities that supports the achievement of its objectives.

5.2 In particular the audit committee will review the adequacy and effectiveness of:

• All risk and control related disclosure statements (in particular the annual governance statement), together with any accompanying Head of Internal Audit Opinion, external audit opinion or other appropriate independent assurances;

• The underlying assurance processes that indicate the degree of achievement of the organisation’s objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements;

• The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and any related reporting and self-certifications;

• The policies and procedures for all work related to counter fraud and security as required by NHS Counter Fraud Authority;

• The policies and procedures for managing conflicts of interest; • The policies and procedures for managing gifts and hospitality.

5.3 In carrying out this work the audit committee will primarily utilise the work of internal audit,

external audit and other assurance functions, but it will not be limited to these sources. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management an internal control, together with an indication of their effectiveness. These will be evidenced through the audit committee’s use of an effective assurance framework to guide its work and the audit and assurance functions that report to it.

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5.4 As part of its integrated approach the audit committee will have effective relationships with other key Governing Body committees so that it underpins processes and linkages. However, these other committees must not usurp the audit committee’s role.

6. Internal Audit 6.1 Each CCG’s audit committee shall ensure that there is an effective internal audit function that

meets the Public Sector Internal Audit Standards 2013 and provides appropriate independent assurance to the audit committee, NCL Accountable Officer and Governing Body. This will be achieved by:

• Considering the provision of the internal audit service and the costs involved; • Reviewing and approving the audit strategy, annual internal audit plan and more

detailed programme of work, ensuring that this is consistent with the audit needs of the organisation as identified in the assurance framework;

• Considering the major findings of internal audit work (and management’s response), and ensuring co-ordination between the internal and external auditors to optimise the use of audit resources;

• Ensuring that the internal audit function is adequately resourced and has appropriate standing within the organisation;

• Monitoring the effectiveness of internal audit and carrying out an annual review.

7. External Audit 7.1 Each CCG’s audit committee shall review and monitor the external auditors’ independence

and objectivity and the effectiveness of the audit process. In particular, the audit committee will review the work and findings of the external auditors and consider the implications and management’s responses to their work. This will be achieved by:

• Considering the appointment and performance of the external auditors; • Discussing and agreeing with the external auditors before the audit commences the

nature and scope of the audit as set out in the annual plan; • Discussing with the external auditors their evaluation of audit risks and assessment of

the organisation and the impact of the audit fee; • Reviewing all external audit reports, including the report to those charged with

governance (before its submission to the Governing Body as appropriate) and any work undertaken outside of the annual audit plan, together with the appropriateness of management responses;

• Ensuring that there is in place a clear policy for the engagement of external auditors to supply non-audit services.

8. Other Assurance Functions 8.1 Each CCG’s audit committee shall review the findings of other significant assurance functions,

both internal and external to the CCG, and consider the implications for the governance of the CCG.

8.2 These will include, but will not be limited to, any reviews by Department of Health arm’s length

bodies or regulators/inspectors (for example, the Care Quality Commission, NHS Litigation Authority etc) and professional bodies with responsibility for the performance of staff or functions (for example, Royal Colleges, accreditation bodies etc).

8.3 In addition, the audit committee will review the work of other committees within the CCG, whose work can provide relevant assurance to the audit committee’s own areas of responsibility.

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9. Counter fraud

9.1 Each CCG’s audit committee shall satisfy itself that the organisation has adequate arrangements in place for counter fraud and security that meet NHS Counter Fraud Authority’s standards and shall review the outcomes of work in these areas. This will be achieved by:

• Considering the provision of the counter fraud service and the costs involved; • Reviewing and approving the counter fraud strategy, annual internal audit plan and

more detailed programme of work, ensuring that this is consistent with the needs of the organisation;

• Considering the major findings of internal audit work and management’s response; • Ensuring that the counter fraud function is adequately resourced and has appropriate

standing within the organisation; • Monitoring the effectiveness of counter fraud and carrying out an annual review.

10. Management

10.1 Each CCG’s audit committee shall request and review reports, evidence and assurances from

directors and managers on the overall arrangements for governance, risk management and internal control.

10.2 Each audit committee may also request specific reports from individual functions within the

organisation. 11. Financial reporting 11.1 Each CCG’s audit committee shall monitor the integrity of the financial statements of its

organisation and any formal announcements relating to its financial performance. 11.2 Each audit committee should ensure that the systems for financial reporting to the Governing

Body, including those of budgetary control, are subject to review as to the completeness and accuracy of the information provided.

11.3 Each audit committee shall review the annual report and financial statements focussing

particularly on: • The wording in the annual governance statement and other disclosures relevant to the

terms of reference of the Committee; • Changes in, and compliance with, accounting policies, practices and estimation

techniques; • Unadjusted misstatements in the financial statements; • Significant judgments in preparation of the financial statements; • Significant adjustments resulting from the audit; • Letters of representation; • Explanations for significant variances; • Ease of understanding of the contents for patients and the public.

12. Whistleblowing 12.1 Each CCG’s audit committee shall review the effectiveness of the arrangements in place for

allowing staff to raise (in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensure that any such concerns are investigated proportionately and independently.

13. Reporting

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13.1 Each CCG’s audit committee shall report to the Governing Body on how it discharges its responsibilities.

13.2 The minutes of the audit committee’s meetings shall be formally recorded by the Secretariat

and submitted to the Governing Body as required. The Chair of the Committee shall draw to the attention of the Governing Body any issues that require disclosure to the full Governing Body, or require executive action.

13.3 Each audit committee will report to the Governing Body at least annually on its work in support

of the annual governance statement, specifically commenting on: • The fitness for purpose of the assurance framework; • The completeness and ‘embeddedness’ of risk management in the organisation; • The integration of governance arrangements; • The appropriateness of evidence that shows the organisation is fulfilling regulatory

requirements relating to its existence as a functioning business; • The robustness of the processes behind the quality accounts.

13.4 The annual report should also describe how the audit committee has fulfilled its terms of

reference and give details of any significant issues that the audit committee considered in relation to the financial statements and how they were addressed.

14. Membership

14.1 When the audit committees are meeting as the NCL Audit Committee in Common or as individual audit committees the membership of each audit committee is as follows:

• The CCG’s Governing Body lay member for audit and governance; • A Governing Body lay member for audit and governance from another NCL Clinical

Commissioning Group; • An additional member who is either:

o A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or

o A second Governing Body lay member for audit and governance from another NCL Clinical Commissioning Group who is a different person that that referred to in the second bullet point of section 14.1 above.

14.2 The membership requirements are summarised in Schedule 2. 14.3 Audit committee members may nominate deputies to represent them in their absence and

make decisions on their behalf. 14.4 The lay member or members for audit and governance from another NCL Clinical

Commissioning Group referred to in the second and third bullet points of paragraph 14.1 above shall be appointed on a non-remunerated basis to the audit committee by the relevant CCG’s Governing Body.

14.5 The list of voting members is contained in Schedule 1.

15. Attendance 15.1 The individual audit committees and the NCL Audit Committee in Common shall have the

following non-voting attendees: • NCL Chief Finance Officer or a nominated deputy; • Head of Internal Audit and internal audit representatives; • External audit representatives;

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• Local Counter Fraud Specialists; • A representative from the NCL Corporate Services Directorate; • A representative from North and East London Commissioning Support Unit, as

required; • Other directors and/or managers as appropriate; • Representatives from other organisations, as required.

15.2 The NCL Accountable Officer will be invited to attend an audit committee meeting at least

once per year to discuss the process for assurance that supports the annual governance statement and the annual report and accounts.

15.3 The individual audit committees and/or the NCL Audit Committee in Common may meet

privately with the internal and external auditors at their absolute discretion. 15.4 Non-voting attendees may nominate deputies to represent them in their absence. 15.5 The individual audit committees and/or the NCL Audit Committee in Common may call

additional experts to attend meetings on a case by case basis to inform discussion. 15.6 The individual audit committees and/or the NCL Audit Committee in Common may invite or

allow additional people to attend meetings as attendees. Attendees may present at meetings and contribute to the relevant discussions but are not allowed to participate in any formal vote.

15.7 The individual audit committees and/or the NCL Audit Committee in Common may invite or

allow people to attend meetings as observers. Observers may not present at meetings, contribute to any discussion or participate in any formal vote.

15.8 The list of non-voting attendees is contained in Schedule 1.

16. Chair and Vice Chair 16.1 The NCL Clinical Commissioning Groups’ Governing Bodies have agreed that the Chair and

Vice Chair of the audit committee shall vary depending on whether the audit committees are meeting as the NCL Audit Committee in Common or individually by themselves.

16.2 When the audit committees are meeting as the NCL Audit Committee in Common the Chair

of the NCL Audit Committee in Common shall be a lay member for audit and governance from either Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG or Islington CCG.

16.3 When the audit committees are meeting as the NCL Audit Committee in Common the Vice

Chair of the NCL Audit Committee in Common shall be a lay member for audit and governance from either Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG or Islington CCG.

16.4 The Chair and the Vice Chair of the NCL Audit Committee in Common shall be from different

CCGs. 16.5 The Chair and Vice Chair of the NCL Audit Committee in Common shall be appointed upon

the agreement of each of the audit committees comprising the NCL Audit Committee in Common.

16.6 When the audit committees are meeting individually by themselves the Chair shall be the lay

member for audit and governance. The Vice Chair shall be another lay member.

16.7 The Chair and Vice Chair requirements are summarised in Schedule 2:

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17. Quoracy

17.1 When the audit committees are meeting as the NCL Audit Committee in Common each audit

committee comprising the NCL Audit Committee in Common must be quorate. Each audit committee is quorate when the following conditions are satisfied:

• At least two members from the respective audit committee or their nominated deputies are present; and

• One of the two members present is from the audit committee’s respective CCG. 17.2 When the audit committees are meeting individually by themselves for the meeting to be

quorate the following conditions must be satisfied: • At least two members or their nominated deputies must be present; and • One of the two members present is from the audit committee’ respective CCG.

17.3 If the NCL Audit Committee in Common is not quorate the individual audit committees have

the option of meeting as individual audit committees at their absolute discretion and as long as the quorum requirements contained in section 17.2 above are satisfied. The individual audit committees may decide to meet at the same time and in the same room as each other at their absolute discretion.

17.4 The quorum requirements are summarised in Schedule 2: 17.5 If any representative is conflicted on a particular item of business they will not count towards

the quorum for that item of business. If this renders a meeting or part of a meeting inquorate a non-conflicted person may be temporarily appointed or co-opted to satisfy the quorum requirements.

18. Voting

18.1 Each CCG’s audit committee shall vote and make decisions for their CCG only. A vote of one CCG’s audit committee is not binding on another CCG’s audit committee.

18.2 Each audit committee member shall have one vote with resolutions passing by simple majority.

The lay member for audit and governance from the respective audit committee’s own CCG or their nominated deputy shall have the casting vote on any resolution.

18.3 When the audit committees are meeting as the NCL Audit Committee in Common the Chair

or Vice Chair of the NCL Audit Committee in Common may not participate in the vote of any individual audit committee unless he or she is a member of that audit committee.

18.4 The voting requirements are summarised in Schedule 2: 19. Decisions 19.1 The individual audit committees will make decisions within the bounds of their remit. 20. Authority and Access 20.1 The individual audit committees and the NCL Audit Committee in Common are Governing

Body committees. They must act within the remit of these terms of reference and have no executive powers other than those specifically set out in these terms of reference.

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20.2 The Head of Internal Audit, representatives of external audit and counter fraud specialists have a right of access to the Chair of the individual audit committees and the Chair of the NCL Audit Committee in Common.

20.3 The individual audit committees and the NCL Audit Committee in Common are authorised by

the Governing Bodies to investigate any activity within these terms of reference. They are authorised to seek any information they require from any employees or officers and all employees and officers are directed to co-operate with any request made in this regard.

20.4 The individual audit committees and the NCL Audit Committee in Common are authorised by

the Governing Bodies to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if they consider this necessary.

21. Secretariat 21.1 The Secretariat to the Committee shall be provided by the NCL Corporate Services

Directorate.

22. Frequency of Meetings 22.1 It is expected that the NCL Audit Committee shall meet four times per year. Whilst it is

expected that most items of business are suitable for the NCL Audit Committee in Common there may be some items which are better suited to being presented to individual audit committees. Therefore, individual audit committees may meet as required. This is expected to be approximately once per year.

22.2 The NCL Audit Committee in Common and/or the individual audit committees may hold additional meetings as required.

23. Notice of Meetings 23.1 Notice of a meeting shall be sent to all members no less than 7 days in advance of the meeting. 23.2 The meeting shall contain the date, time and location of the meeting.

24. Agendas and Circulation of Papers 24.1 Before each meeting an agenda setting out the business of the meeting will be sent to every

member no less than 7 days in advance of the meeting. 24.2 Before each meeting the papers of the meeting will be sent to every member no less than 7

days in advance of the meeting. 24.3 If a member wishes to include an item on the agenda they must notify the Chair via the

Secretariat no later than 7 days prior to the meeting. The decision as to whether to include the agenda item is at the absolute discretion of the Chair.

25. Minutes and Reporting 25.1 The minutes of the proceedings of a meeting shall be prepared by the Secretariat and

submitted for agreement at the following meeting. 25.2 Each individual CCG will comply with their own Governing Body’s reporting requirements.

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26. Conflicts of Interest 26.1 Conflicts of Interest shall be dealt with in accordance with the NCL Conflicts of Interest Policy

and NHS England statutory guidance for managing conflicts of interest. The NCL Conflicts of Interest Policy is a master document containing the single conflicts of interest policy agreed by each of the NCL CCGs together with a schedule setting out each CCG’s local variations to that policy.

26.2 The individual audit committees and the NCL Audit Committee in Common shall have a Conflicts of Interest Register that will be presented as a standing item on the agenda.

27. Gifts and Hospitality 27.1 Gifts and Hospitality shall be dealt with in accordance with the NCL Conflicts of Interest Policy

and NHS England statutory guidance for managing conflicts of interest. 27.2 The individual audit committees and the NCL Audit Committee in Common shall have a Gifts

and Hospitality Register that will be presented as a standing item on the agenda. 28. Standards of Business Conduct 28.1 Members, attendees and/or observers must maintain the highest standards of personal

conduct and in this regard must comply with: • The law of England and Wales; • The NHS Constitution; • The Nolan Principles; • The standards of behaviour set out in each NCL CCG Constitution; • Any additional regulations or codes of practice relevant to the Committee.

29. Training and Information 29.1 It is the responsibility of each organisation referred to in section 1.3 above to ensure that their

representatives are provided with appropriate training and information to allow them to exercise their responsibilities effectively.

30. Quick Reference Guide 30.1 A quick reference guide to the voting members, chair, vice chair, quoracy, voting methodology

and casting votes of the individual audit committees and the NCL Audit Committee in Common can be found in Schedule 2.

31. Review of Terms of Reference 31.1 These Terms of Reference will be reviewed from time to time, reflecting experience of the

individual audit committees and the NCL Audit Committee in Common in fulfilling its functions and the wider experience of CCGs in overseeing a common system of controls.

31.2 These Terms of Reference will be formally reviewed annually. These Terms of Reference

may be changed or amended by mutual agreement of the individual audit committees and the NCL Audit Committee in Common and on being approved by each of the Governing Bodies of the NCL Clinical Commissioning Groups in accordance with their Constitutions.

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Schedule 1 List of Members

This schedule sets out the membership, attendees, Chair and Vice Chair of each individual audit committee and the NCL Audit Committee in Common. NCL Audit Committee in Common: The voting members of the NCL Audit Committee in Common are as follows: Committee Voting Members Name and Title Barnet CCG Audit Committee

Lay member for audit and governance from Barnet CCG

Dominic Tkaczyk

Barnet CCG Audit Committee

Lay member for audit and governance from another NCL Clinical Commissioning Group

Karen Trew

Barnet CCG Audit Committee

A person who is either: • A Governing Body

member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or

• A second lay member for audit and governance from another NCL Clinical Commissioning Group

Ian Bretman

Camden CCG Audit Committee

Lay member for audit and governance from Camden CCG

Richard Strang



Dominic Tkaczyk



member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the

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CCG Governing Body; or


Enfield CCG Audit Committee

Lay member for audit and governance from Enfield CCG

Karen Trew



Adam Sharples





Haringey CCG Audit Committee

Lay member for audit and governance from Haringey CCG

Adam Sharples



Lucy De Groot




• A second lay member for audit and governance from another NCL Clinical

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Commissioning Group.

Islington CCG Audit Committee

Lay member for audit and governance from Islington CCG

Lucy De Groot



Richard Strang




• A second lay member for audit and governance from another NCL Clinical Commissioning Group.

Chair and Vice Chair of the NCL Audit Committee in Common Position Name and Title CCG Chair

Adam Sharples Haringey

Vice Chair

Dominic Tkaczyk Barnet

Individual Audit Committees: Barnet CCG Audit Committee The voting members of the Barnet CCG Audit Committee are as follows: Position Name Title Lay member for audit and Governance from Barnet CCG

Dominic Tkaczyk


Karen Trew


member who is not the NCL Accountable Officer

Ian Bretman

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nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or


Chair Lay Member for Audit and

Governance at Barnet CCG Camden CCG Audit Committee The voting members of the Camden CCG Audit Committee are as follows: Position Name Title Lay member for audit and governance from Camden CCG

Richard Strang


Dominic Tkaczyk

A person who is either: • Governing Body




Governance at Camden CCG

Enfield CCG Audit Committee The voting members of the Enfield CCG Audit Committee are as follows: Position Name Title

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Lay member for audit and governance from Enfield CCG

Karen Trew


Adam Sharples





Governance at Enfield CCG

Haringey CCG Audit Committee The voting members of the Haringey CCG Audit Committee are as follows: Position Name Title Lay member for audit and governance from Haringey CCG

Adam Sharples


Lucy De Groot



• A second lay member for audit and governance from another NCL Clinical

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Commissioning Group


Governance at Haringey CCG

Islington CCG Audit Committee The voting members of the Islington CCG Audit Committee are as follows: Position Name Title Lay member for audit and governance from Islington CCG

Lucy De Groot


Richard Strang





Governance at Islington CCG

Attendees The non-voting attendees at the individual audit committees and the NCL Audit Committee in

Common are:

Position Name Title NCL Accountable Officer Ms Helen Pettersen NCL Accountable Officer NCL Chief Finance Officer Mr Simon Goodwin NCL Chief Finance Officer Head of Internal Audit and Internal Audit Representatives

Mr Clive Makombera

External Audit Representatives

Local Counter Fraud Specialists

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A representative from the NCL Corporate Services Directorate

A representative from North and East London Commissioning Support Unit

The roles referred to in the list of voting members and non-voting attendees above describe the members’ and non-voting attendees’ substantive roles and/or any successor equivalent roles only and not the individual title or titles of any member. Names and job titles are provided for information purposes only and may be updated as required without the need to formally amend the Terms of Reference.

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Schedule 2 Quick Reference Guide

No Meeting Voting Members Chair Vice Chair Quoracy Voting

Methodology Casting Vote

1. Audit committee when meeting as part of the NCL Audit Committee in Common

The Governing Body lay member for audit and governance. The lay Member for audit and governance from another NCL Clinical Commissioning Group A person who is either:

• A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or


The lay member or members for audit and governance from another NCL Clinical Commissioning Group referred to above shall be appointed on a non-remunerated basis to the audit committee by the relevant CCG’s Governing Body.

A lay member for audit and governance from an NCL CCG

A lay member for audit and governance from an NCL CCG but from a different CCG than the Chair

Two members from each of the five individual audit committees or their nominated deputies must be present. One member must be from the respective CCG. Each of the five individual audit committees must be present for the NCL Audit Committee in Common to be quorate. If the NCL Audit Committee in Common is not quorate the individual audit committees may decide to meet at the same time and in the same room as each other at their absolute discretion.

Resolutions of each individual CCG’s audit committee pass by simple majority. A vote of one CCG’s audit committee is not binding on any other CCG’s audit committee.

The audit committee lay member for audit and governance or their nominated deputy

2. Audit committee when meeting individually by itself and not as part of the NCL Audit Committee in Common.

The Governing Body lay member for audit and governance. The lay Member for audit and governance from another NCL Clinical Commissioning Group A person who is either:

• A Governing Body member who is not the NCL Accountable Officer nor the NCL Chief Finance Officer nor the Chair of the CCG Governing Body; or

The CCG’s lay member for audit and governance

Another lay member

Two members or their nominated deputies. One member must be from the respective CCG.

Resolutions pass by simple majority.

The audit committee Chair or their nominated deputy

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The lay member or members for audit and governance from another NCL Clinical Commissioning Group referred to above shall be appointed on a non-remunerated basis to the audit committee by the relevant CCG’s Governing Body.

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